Every finding on record at Marina Pointe Healthcare & Subacute

Based on interview and record review, the facility failed to ensure resident's rights were maintained for one of three sampled residents (Resident 1) when the facility did not honor Resident 1's family's preference for no male staff on 7/26/2026. This deficient practice created the potential for Resident 1 to experience psychosocial distress related to receipt of care from a male caregiver and refuse necessary care and interventions. Cross Reference F656Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 1's admitting diagnoses included chronic respiratory failure (a chronic condition where the lungs cannot properly transfer oxygen into the bloodstream), dysphasia (a language disorder caused by damage to the brain), presence of a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), adult failure to thrive (a gradual decline in physical and mental health), dementia (a progressive state of decline in mental abilities), and altered mental status. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/23/2026, the MDS indicated Resident 1 had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of the facility staffing assignment, dated 7/26/2026, the staffing assignment indicated Certified Nursing Assistant (CNA) 1 was assigned to Resident 1's care. During a telephone interview on 8/5/2026 at 12:42 p.m., with Resident 1's Responsible Party (RP), RP 1, RP 1 stated that sometime in 4/2026, she and other family members communicated to the facility that they did not want male staff providing care to Resident 1. RP 1 stated the facility was aware of the request. During a telephone interview on 8/5/2026 at 3:35 p.m., with Resident 1's Family Member (FM), FM 1, FM 1 stated that on 7/27/2026, he asked the Director of Staff Development (DSD) why a male CNA (CNA 1) was assigned to provide care to Resident 1 on 7/26/2026. FM 1 stated the DSD could not provide an answer to his question, and she stated the facility was aware of the family's request for no male caregiver staff. FM 1 stated the DSD stated this request was documented in a book. During an interview on 8/6/2026 at 2:50 p.m., with the DSD, the DSD stated Resident 1's family requested that Resident 1 have no male caregiver staff due to Resident 1's increased resistance to care when provided by a male caregiver. The DSD stated this request was documented in the staffing assignment book but was not documented in Resident 1's care plan. The DSD stated it was important for this preference to be documented in a care plan to ensure staff were aware of it. The DSD stated that on 7/26/2026, the CNAs chose their own resident assignments, and CNA 1 picked the resident assignment that included Resident 1. The DSD stated the supervising licensed nurse should have reviewed the preferences and adjusted the assignment to ensure Resident 1's family's preference was honored. During a telephone interview, on 8/6/2026 at 4:09 p.m., with CNA 1, CNA 1 stated he was aware of the documented resident preferences kept in the staffing assignment book, but he could not recall reviewing the book or being informed of Resident 1's family's request. CNA 1 stated that on 7/26/2026 the CNAs chose their own assignments, and stated the only assignment left when he arrived was the assignment that included Resident 1. During an interview on 8/7/2026 at 1:01 p.m., with the Director of Nursing (DON), the DON stated it was Resident 1's right to receive care in the way they preferred. The DON stated these preferences were documented in the staffing assignment book and were to be reviewed by the shift's licensed nurses to ensure they were honored. The DON stated Resident 1's family's preference was overlooked on 7/26/2026. During a review of the facility's policy and procedure (P&P) titled Resident Rights, revised 2/2021, the P&P indicated employees were to treat all residents with kindness, respect, and dignity. The P&P indicated facility residents had the right to self-determination (the power or right to make decisions for yourself without outside control). During a review of the facility's P&P titled Daily Work Assignments, revised 8/2006, the P&P indicated work assignments were to be prepared from the resident's care plan by the Nurse Supervisor/Charge Nurse. The P&P indicated changes in work assignments were to be approved by the Nurse Supervisor/Charge Nurse.

Based on interview and record review, the facility failed to ensure the use of physical restraints for two of two sampled residents (Resident 1 and Resident 3) was implemented in accordance with the facility's policies and procedures (P&Ps) when: 1. There was no documented evidence of the Interdisciplinary Team (IDT, a coordinated group of healthcare professionals from different disciplines who work together to plan and evaluate patient care) assessing the appropriateness of physical restraints, prior to their use, for Resident 1 and Resident 3. 2. Informed consent for the use of restraints was not obtained by the physician for Resident 1 and Resident 3. These deficient practices placed Resident 1 and Resident 3 at risk of being restrained without indication and/or without the consent of their respective responsible parties (RPs).Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 1's admitting diagnoses included chronic respiratory failure (a chronic condition where the lungs cannot properly transfer oxygen into the bloodstream), dysphasia (a language disorder caused by damage to the brain), presence of a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), adult failure to thrive (a gradual decline in physical and mental health), dementia (a progressive state of decline in mental abilities), and altered mental status. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/23/2026, the MDS indicated Resident 1 had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of Resident 1's physician order, dated 11/8/2025, the order indicated staff were to apply a mitten restraint (a padded, hand-enclosing medical device) to Resident 1's right hand during care due to combative behavior during care. a. During a review of Resident 1's record titled Physical Restraint Screen/Assessment, dated 11/7/2025, the assessment indicated the reason for the mitten restraint was Resident 1's poor judgement and aggressive behavior. The assessment indicated staff were to refer to the Interdisciplinary Team (IDT) to review for possible restraint reduction. During an interview on 8/7/2026 at 12:14 p.m., with the Director of Nursing (DON), the DON stated there was no documentation that the IDT assessed the appropriateness of Resident 1's use of restraints started on 11/7/2025. b. During a review of Resident 1's Progress Note, dated 11/7/2025, documented by Registered Nurse (RN) 2, the progress note indicated RN 2 called and spoke to Resident 1's Responsible Party (RP 1) regarding the resident's right hand mitten. RN 2 explained the risks and benefits. RP 1 understood and verbalized understanding and gave consent witnessed by another licensed RN. 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 3's diagnoses included limited use of or inability to move her left side, aphasia (a brain disorder that affects how you speak, write, and understand words), and cognitive communication deficit (a trouble with communication caused by disrupted thinking skills-like memory, focus, and planning). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severe cognitive impairment. The MDS indicated Resident 3 was dependent on staff for all ADLs and mobility while in and out of bed. During a review of Resident 3's physician order, dated 3/23/2026, the order indicated staff were to apply a mitten restraint to Resident 3's left hand at all times to prevent her from pulling out her tracheostomy (a curved plastic or metal tube placed inside a surgically made hole in the front of the neck and into the windpipe) and gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). a. During a review of Resident 3's record titled Interdisciplinary Care Conference, dated 3/17/2026, the record did not indicate the application of a mitten restraint to Resident 3 was discussed. During a review of Resident 3's record titled Physical Restraint Screen/Assessment, dated 4/21/2026, the assessment indicated Resident 3's mitten restraint was required due to the behavior of pulling out her G-tube which placed her at risk for injury. The assessment did not indicate the use of restraints was to be referred to the IDT to review for possible restraint reduction. During an interview on 8/7/2026 at 12:24 p.m., with the DON, the DON stated there was no documentation in Resident 3's medical record indicating the IDT discussed Resident 3's use of restraints prior to or after the initiation of their application. b. During a review of Resident 3's record titled Verification of Informed Consent for Physical Restraint, dated 3/23/2026, the record indicated informed consent for the use of a mitten restraint was provided by Resident 3's RP, RP 2. The record further indicated Licensed Vocational Nurse (LVN) 1 verified the physician obtained consent from RP 2 for the use of the mitten restraint. During a telephone interview on 8/7/2026 at 10:02 a.m., with RP 2, RP 2 stated the mitten restraint was used to prevent Resident 3 from placing herself at risk for injury. RP 2 stated he did not speak with the physician regarding the mitten restraint. RP 2 stated he did not want Resident 3 to have the mitten restraint applied at all times because he did not want Resident 3 to feel restricted. RP 2 stated Resident 3's medical condition prevented her from being able to inform staff if the mitten restraint was bothering her. RP 2 stated he did not know the informed consent he signed was for the mitten restraint to be in place at all times. RP 2 stated that if he had known the order was to apply the mitten at all times, he would not have signed the consent. During a telephone interview on 8/7/2026 at 10:23 a.m., with LVN 1, LVN 1 stated the process for obtaining informed consent for use of restraints required the licensed nurse first explaining the use of restraints to the resident or their RP, and if the resident or their RP was agreeable, the physician would not be involved. LVN 1 stated the signatures of the licensed nursing staff on the informed consent were to indicate that the resident/RP consented to the ordered treatment. LVN 1 stated the ordering physician only spoke with the resident/RP if they had additional questions that the licensed nurse was not able to answer. During an interview on 8/7/2026 at 12:26 p.m., with the DON, the DON stated the facility policy and procedure (P&P) titled Physical Restraint Policy, dated 4/2026, indicated that a physician's order was not enough to warrant the use of a physical restraint. The DON stated the P&P indicated the IDT was responsible for determining appropriateness of the use of restraints. The DON stated there should have been an IDT meeting for Resident 1 and Resident 3 prior to initiating the use of the restraints. The DON stated that obtaining informed consent for the use of restraints ensured the resident and/or RP consented to their use, and stated residents and/or RPs had the right to refuse use of restraints. The DON stated that the licensed nursing staff were not to be the only staff explaining the procedure treatment in the informed consent. During a review of the facility's P&P titled Informed Consent, dated 12/2022, the P&P indicated it was the responsibility of the healthcare professional who proposes any medical intervention that requires informed consent to obtain the informed consent from the resident or their responsible party. The P&P indicated that prior to initiating the use of a physical restraint, licensed nursing staff were to verify with the resident or their responsible party that informed consent was obtained. The P&P did not indicate the licensed nursing staff were responsible for obtaining the informed consent. During a review of the facility's P&P titled Physical Restraint Policy, dated 5/2026, the P&P indicated a physician's order alone was not sufficient to warrant the use of a physical restraint. The P&P indicated that before a resident was restrained, the IDT was to determine the appropriateness of the use of restraints.

Based on interview and record review, the facility failed to report an injury of unknown origin to the State Agency (SA) for one of one sampled resident (Resident 1), after it was identified on 4/19/2026. This deficient practice created the potential for unidentified abuse, and a delayed investigation by the SA, related to the cause of Resident 1's injury.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 1's diagnoses included dysphasia (a language disorder caused by damage to the brain), dementia (a progressive state of decline in mental abilities), and altered mental status. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/23/2026, the MDS indicated Resident 1 had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of Resident 1's Change of Condition (COC) assessment, dated 4/19/2026, the assessment indicated on 4/19/2026 at 1:30 p.m., Resident 1's Family Member (FM) 2 reported to Licensed Vocational Nurse (LVN) 1 that Resident 1 had dark skin discoloration and swelling to the area around her left eye. During a review of Resident 1's progress note, dated 4/19/2026, the progress note did not indicate Resident 1 had any recent incidents, falls, or trauma reported or documented prior to the observation of the dark discoloration and swelling to the resident's left eye. During a review of the facility staffing assignment, dated 4/19/2026, the staffing assignment indicated on 4/19/2026, Certified Nursing Assistant (CNA) 3 was assigned to Resident 1's care. During a review of an untitled document (undated), the document indicated the Director of Staff Development (DSD) created the document. The document indicated the licensed nurse making the staffing assignment was informed that Resident 1's family did not want CNA 3 assigned to Resident 1's care. The document did not indicate the reason for the request. During an interview on 8/7/2026 at 9:31 a.m., with the DSD, the DSD stated CNA 3 worked the 7:00 a.m. to 3:00 p.m. shift. The DSD stated that sometime in 2026, Resident 1's family made a request for CNA 3 to not be assigned to Resident 1's care. The DSD could not recall the exact date. The DSD stated Resident 1's family claimed Resident 1 was pointing a lot at CNA 3. The DSD stated she spoke with Family Member (FM) 2 and FM 2 told her (DSD) that Resident 1's pointing indicated something was not right, or off, and as a precaution, CNA 3 was removed indefinitely from Resident 1's care. During a telephone interview 8/7/2026 at 10:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 4/19/2026, FM 2 reported Resident 1 had dark discoloration around her eye. LVN 1 stated he documented the COC assessment, dated 4/19/2026. LVN 1 stated the dark discoloration was a new change and stated he did not know where the discoloration and swelling came from. LVN 1 stated he also asked unspecified CNAs if they were aware of the dark discoloration or where it came from, and the CNAs stated they did not know where the discoloration and swelling came from. LVN 1 stated Resident 1 was non-verbal but was alert and could use gestures to communicate her needs and wants with staff. LVN 1 stated he was a mandated reporter, but he only documented the new skin discoloration as a change of condition, and but did not report it as an injury of unknown origin. LVN 1 stated he reported the discoloration to the facility's Director of Nursing (DON) and Administrator (ADM). LVN 1 stated he was not sure what happened after reporting the change to the DON and ADM. During an interview on 8/7/2026 at 1:11 p.m., with the DON, the DON stated she investigated Resident 1's discoloration and swelling to the left eye. The DON stated the discoloration and swelling were investigated based on their appearance, and to ensure potential abuse was ruled out. The DON stated the investigation concluded that abuse did not occur, and therefore the facility did not report the left eye discoloration or swelling to the State Agency (SA). During a review of the facility's policy and procedure (P&P) titled Abuse Reporting and Investigation, dated 1/2024, the P&P indicated that all allegations of abuse, including injury of unknown origin, were to be reported by the facility to the SA immediately. The P&P indicated the conclusion of investigations into allegations of abuse, including injury of unknown origin, were to be documented by the facility's ADM. The P&P did not indicate reporting to the SA was based on the conclusion of the investigation.

Based on interview and record review, the facility failed to ensure a care plan was developed for one of three sampled residents (Resident 1) to reflect the residents' family's preference for no male caregivers. This deficient practice resulted in Resident 1 being provided care by a male caregiver on 7/26/2026.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 1's admitting diagnoses included chronic respiratory failure (a chronic condition where the lungs cannot properly transfer oxygen into the bloodstream), dysphasia (a language disorder caused by damage to the brain), presence of a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), adult failure to thrive (a gradual decline in physical and mental health), dementia (a progressive state of decline in mental abilities), and altered mental status. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/23/2026, the MDS indicated Resident 1 had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of the facility staffing assignment, dated 7/26/2026, the staffing assignment indicated on 7/26/2026, Certified Nursing Assistant (CNA) 1 was assigned to Resident 1's care. During a telephone interview on 8/5/2026 at 12:42 p.m., with Resident 1's Responsible Party (RP), RP 1, RP 1 stated that sometime in 4/2026, she and other family members communicated to the facility that they did not want male staff assigned to care for Resident 1. RP 1 stated the facility was aware of the request. During a telephone interview on 8/5/2026 at 3:35 p.m., with Resident 1's Family Member (FM), FM 1, FM 1 stated that on 7/27/2026, he asked the Director of Staff Development (DSD) why a male CNA (CNA 1) was assigned to provide care to Resident 1 on 7/26/2026. FM 1 stated the DSD could not provide an answer to his question, and she stated the facility was aware of the family's request for no male staff. FM 1 stated the DSD stated this request was documented in a book. During an interview on 8/6/2026 at 2:50 p.m., with the DSD, the DSD stated Resident 1's family requested that Resident 1 have no male caregiver staff due to Resident 1's increased resistance to care when provided by a male caregiver. The DSD stated this request was documented in the staffing assignment book but was not care planned. The DSD stated it was important for this preference to be care planned to ensure staff were aware of it. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated the resident's comprehensive, person-centered care plan was to reflect the resident's expressed wishes regarding care.

Based on interview and record review, the facility failed to ensure care plans were revised for one of three sampled residents (Resident 3) when Resident 3's care plan was not revised to reflect her use of a low air loss mattress (LALM, a specialized medical bed system that uses a continuous airflow to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] in immobile patients). This deficient practice resulted in Resident 3's LALM not being set in accordance with her weight, increasing her risk for pressure ulcer development.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 3's diagnoses included limited use of or inability to move her left side, aphasia (a brain disorder that affects how you speak, write, and understand words), and cognitive communication deficit (a trouble with communication caused by disrupted thinking skills-like memory, focus, and planning). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2026, the MDS indicated Resident 3 had no speech, and had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 3 was dependent on staff for repositioning while in bed. The MDS indicated Resident 3 was at risk for developing pressure ulcers. During a review of Resident 3's physician order, dated 3/2/2026, the order indicated Resident 3 was to have a LALM while in bed for skin care maintenance and integrity. During a review of Resident 3's care plan titled At Risk for Skin Breakdown/ Further Skin Breakdown., last revised 6/13/2026, the care plan indicated goals of care included Resident 3 maintaining skin integrity and minimization of skin breakdown/pressure ulcer formation through interventions. The interventions listed on the care plan did not include the use of a LALM, including instructions for use. During an interview on 8/7/2026 at 11:17 a.m., with the Treatment Nurse (TN), the TN stated that the use of a LALM was to be indicated in the resident's care plan. Stated that the purpose of indicating LALM use in the care plan was to ensure the other nursing staff are aware of the intervention and instructions for use. During a review of the facility's policy and procedure (P&P) titled Pressure Injury Prevention and Management, dated 5/2026, the P&P indicated interventions for prevention of pressure ulcers were to be implemented for all residents assessed at risk for developing pressure ulcers, including provision of appropriate, pressure-redistributing support surfaces. The P&P indicated interventions were to be documented in the care plan and communicated to relevant staff. The P&P indicated that interventions on the care plan were to be modified as needed.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 notified Registered Nurse (RN) 1 of a resident being struck in the head and chest with a metal pole and enteral feeding pump (a computerized medical device that delivers liquid nutrition and hydration directly into a patient's stomach or small intestine) and change of condition for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk of receiving delayed assessment and intervention after a metal pole and enteral feeding pump fell and struck Resident 1 on her head and chest. This deficient practice also placed Resident 1 at risk of receiving delayed assessment and intervention in response to her unresolved cough and difficulty breathing. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 1's admitting diagnoses included dysphasia (a language disorder caused by damage to the brain), presence of a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dementia (a progressive state of decline in mental abilities), and altered mental status. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/23/2026, the MDS indicated Resident 1 had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. a. During a review of Resident 1's progress note, dated 7/26/2026, the progress note indicated on 7/26/2026, during care, Resident 1 pulled on the metal pole her enteral feeding pump was attached to. The progress note indicated this caused the pole and pump to fall and hit Resident 1's head. During a telephone interview, on 8/6/2026 at 10:31 a.m., with Registered Nurse (RN) 1, RN 1 stated on 7/26/2026, she was seated at the nurse's station on 7/26/2026 when she heard someone crying out in an exclamation of pain. RN 1 stated she followed the sound to Resident 1's room where she saw Certified Nursing Assistant (CNA) 1 at Resident 1's bedside. RN 1 stated Resident 1 was still making sounds that sounded like she was in pain. RN 1 stated she asked CNA 1 what happened, and CNA 1 told her Resident 1 had become agitated and pulled on the metal pole causing it to fall and hit her in the head. RN 1 stated Resident 1 had a facial expression of distress when she arrived at the bedside. During a telephone interview on 8/6/2026 at 4:09 p.m., with CNA 1, CNA 1 stated he was providing perineal care (cleaning and caring for the genital and anal areas) and a linen change to Resident 1 when she pulled on the metal pole with her feeding pump attached. CNA 1 stated the pole and pump fell onto Resident 1, and after the incident occurred, Resident 1 was moaning and gesturing towards her head with her right hand. Resident 1 was touching the right side of her head, and she was frowning and appeared unhappy. CNA 1 stated as he continued with Resident 1's perineal care and linen change the resident became physically combative. Resident 1 was attempting to strike him (CNA 1) while still moaning. CNA 1 stated RN 1 entered the room before he completed the care. CNA 1 stated he did not call for RN 1 or request her help. CNA 1 stated he continued providing care after the accident occurred because he did not see any visible injury or bleeding. CNA 1 stated he could have notified RN 1 sooner, even if there were no visible injuries. During an interview on 8/6/2026 at 2:38 p.m., with the Director of Staff Development (DSD), the DSD stated the metal pole and enteral feeding pump falling onto and striking Resident 1 could result in visible and non-visible injuries. The DSD stated that even if there were no outward visible injuries, there was risk for internal bleeding in Resident 1's head. During an interview on 8/7/2026 at 12:53 p.m., with the Director of Nursing (DON), the DON stated that if a pole and feeding pump were to fall and hit a resident, the CNA should report the incident immediately. The DON stated it was important to report the incident immediately for patient safety, and to identify if intervention was necessary. The DON stated it was not within the CNA's scope to determine if intervention was needed. The DON stated the CNA should notify the RN right away, even if there was no visible injury. The DON stated the incident created the risk for bone fracture, skin discoloration, and concern for possible neurological changes. b. During a review of Resident 1's Change of Condition (COC) Assessment, dated 7/26/2026, the assessment indicated that on 7/26/2026, Resident 1's Family Member (FM), FM 1, notified RN 1 that he believed something was wrong with Resident 1. The assessment indicated RN 1 immediately went to assess Resident 1 and her oxygen saturation (measurement of how much oxygen the blood is carrying as a percentage) was 68% (normal oxygen saturation ranges from 95% to 100%), and she had grunting respirations. The assessment indicated Resident 1 was suctioned (using negative pressure to pull fluids, blood, mucus, or other blockages from the airway), and the Respiratory Therapist (RT) administered oxygen at 15 liters per minute (L/min, a unit of measuring oxygen flow rate) through a non-rebreather mask (a device that gives you oxygen, usually in an emergency). The assessment indicated Resident 1's oxygen saturation increased to 95% and she was able to respond to verbal stimuli. During a review of Resident 1's progress note, dated 7/26/2026, the progress note indicated on 7/26/2026, Resident 1 was transferred to the General Acute Care hospital on 7/26/2026 at 10:25 p.m., accompanied by emergency services personnel. During a telephone interview on 8/5/2026 at 3:35 p.m., with FM 1, FM 1 stated he visited the facility on 7/26/2026 after being notified a pole had fallen onto Resident 1. FM 1 stated that when he arrived at Resident 1's bedside, CNA 1 was standing at Resident 1's bedside and Resident 1 had labored breathing. FM 1 stated Resident 1's eyes were closed, and she would not respond when he called her name. FM 1 stated Resident 1 was trying to cough and was gasping for air. FM 1 stated he asked CNA 1 to get a doctor or call for help, and stated CNA 1 did not move. FM 1 stated he went to the nurse's station to get help and returned to the room with RN 1. FM 1 stated CNA 1 was still in the room when they returned, and Resident 1 was still having a hard time breathing and was not responding when spoken to. During a telephone interview on 8/6/2026 at 10:31 a.m., with RN 1, RN 1 stated, FM 1 arrived at the facility about two hours after the pole and feeding pump fell onto Resident 1. RN 1 stated she saw FM 1 go directly to Resident 1's room. RN 1 stated FM 1 approached her at the nurse's station shortly after going to Resident 1's room. RN 1 stated FM 1 told her Resident 1 did not look good. RN 1 stated she went to Resident 1's room with FM 1 and she saw Resident 1 grunting. RN 1 stated Resident 1 would usually respond when you call her name, but upon assessment, Resident 1's eyes were open, but she was not responding as usual. RN 1 stated Resident 1's oxygen saturation was low, and she heard gurgling coming from Resident 1's mouth while Resident 1 was breathing. RN 1 stated emergency personnel were contacted, and the RT suctioned Resident 1 and applied oxygen. RN 1 stated Resident 1's oxygen saturation increased, and she was responsive to verbal stimuli after their interventions. During a telephone interview on 8/6/2026 at 4:09 p.m., with CNA 1, CNA 1 stated Resident 1 sometimes coughed after care was provided. CNA 1 stated it would sound like she was congested or had something in her throat, but she did not usually get short of breath during care. CNA 1 stated he had just finished providing perineal care and a linen change to Resident 1 when she exhibited a strong cough that sounded like she needed to cough something up. CNA 1 stated Resident 1 was coughing during the perineal care and linen change, and upon completion of care, her coughing had increased. CNA 1 stated he elevated the head of her bed and proceeded to clean up the used supplies and put them away while observing her. CNA 1 stated he thought she might eventually cough and clear something from her airway. CNA 1 stated he could have notified a licensed nurse sooner when Resident 1's cough continued to increase and was not improving. CNA 1 stated it was not within his scope to assess or make clinical judgement decisions. CNA 1 stated the priority in that situation was to notify the licensed nurse and CNA 1 stated he could have stopped what he was doing to get help sooner. During an interview on 8/7/2026 at 12:59 p.m., with the DON, the DON stated that if a resident were to begin coughing or appeared to be in respiratory distress following care, the CNA should report it to the licensed nurse right away. The DON stated that timely notification of the licensed nurse was important because the resident might require additional intervention. During a review of the facility's job description titled Certified Nursing Assistant, dated 2003, the job description indicated that CNAs were expected to report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practical.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, a specialized medical bed system that uses a continuous airflow to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] in immobile patients) settings were in accordance with the resident's weight for two of two sampled residents (Resident 2 and Resident 3). This deficient practice placed Resident 2 and Resident 3 at risk of developing pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).Findings: 1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 3's diagnoses included limited use of or inability to move her left side, aphasia (a brain disorder that affects how you speak, write, and understand words), and cognitive communication deficit (a trouble with communication caused by disrupted thinking skills -like memory, focus, and planning). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2026, the MDS indicated Resident 3 had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 3 was dependent on staff for repositioning while in bed. The MDS indicated Resident 3 was at risk for developing pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 3's assessment titled Braden Scale - for Predicting Pressure Ulcer Risk Evaluation, dated 5/29/2026, the assessment indicated Resident 3 was at high risk for developing pressure ulcers. During a review of Resident 3's physician order, dated 3/2/2026, the order indicated to provide a low air loss mattress (LALM) while in bed for skin care maintenance and integrity. During a review of Resident 3's record titled Bodyweight, dated 8/4/2026, the record indicated Resident 3's bodyweight was 128 pounds (lbs., a unit of weight measurement). During an observation on 8/7/2026 at 8:38 a.m., at Resident 3's bedside, Resident 3 was observed lying on a LALM. The LALM was set for a weight of 200 lbs. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and was most recently readmitted on [DATE]. Resident 2's diagnoses included metabolic encephalopathy (a general term for brain dysfunction caused by an underlying systemic illness, organ failure, or chemical imbalance in the blood) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 was dependent on staff for repositioning while in bed. The MDS indicated Resident 2 was at risk for developing pressure ulcers. During a review of Resident 2's assessment titled Braden Scale - for Predicting Pressure Ulcer Risk Evaluation, dated 6/29/2026, the assessment indicated Resident 2 was at high risk for developing pressure ulcers. During a review of Resident 2's physician order, dated 1/15/2026, the order indicated Resident 2 was to have a LALM while in bed. During a review of Resident 2's care plan titled At Risk for Skin Breakdown/ Further Skin Breakdown related to Fragile Skin, dated 3/15/2026, the care plan indicated staff were to set Resident 2's LALM in accordance with her bodyweight. During a review of Resident 2's record titled Bodyweight, dated 8/4/2026, the record indicated Resident 3's bodyweight was 153 lbs. During an observation on 8/7/2026 at 8:38 a.m., at Resident 2's bedside, Resident 2 was observed lying on a LALM. The LALM was set for a weight of 280 lbs. During an interview on 8/7/2026 at 11:17 a.m., with the Treatment Nurse (TN), the TN stated that a LALM worked by distributing weight and helped with wound healing and prevention of skin breakdown. The TN stated that the higher the weight setting, the firmer the mattress, and the lower the weight setting, the softer the mattress. The TN stated a firmer mattress applied higher pressure on the resident's skin and unnecessary pressure on the skin could increase the risk for pressure injury development. During a review of the facility's policy and procedure (P&P) titled Pressure Injury Prevention and Management, dated 5/2026, the P&P indicated interventions for prevention of pressure ulcers were to be implemented for all residents assessed at risk for developing pressure ulcers, including provision of appropriate, pressure-redistributing support surfaces.

Based on interview and record review, the facility failed to ensure safety was maintained for one of three sample residents (Resident 1) when staff failed to develop a care plan addressing Resident 1's known behavior of pulling on the rolling metal pole in which her enteral feeding pump (a computerized medical device that delivers liquid nutrition and hydration directly into a patient's stomach or small intestine) was attached. This deficient practice resulted the metal pole falling on Resident 1 and striking her on the face and chest.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 1's admitting diagnoses included dysphasia (a language disorder caused by damage to the brain), presence of a gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and dementia (a progressive state of decline in mental abilities), and altered mental status. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/23/2026, the MDS indicated Resident 1 had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of Resident 1's progress note, dated 2/15/2026, documented by Registered Nurse (RN) 3, the progress note indicated on 2/15/2026, Resident 1 attempted to grab the metal pole at her bedside. During a review of Resident 1's progress note, dated 3/9/2026, documented by RN 3, the progress note indicated on 3/9/2026, Resident 1 grabbed the metal pole at her bedside, causing it to fall to the floor. The progress note indicated the incident caused Resident 1's bedside table to break. During a review of Resident 1's progress note, dated 7/26/2026, the progress note indicated on 7/26/2026, during care, Resident 1 pulled on the metal pole and the pole hit Resident 1's head. During a telephone interview, on 8/6/2026 at 10:40 a.m., with RN 1, RN 1 stated on 7/26/2026, she was seated at the nurse's station when she heard someone crying out in an exclamation of pain. RN 1 stated she followed the sound to Resident 1's room where she saw Certified Nursing Assistant (CNA) 1 at Resident 1's bedside. RN 1 stated Resident 1 sounded like she was in pain. RN 1 stated she asked CNA 1 what happened, and CNA 1 told her Resident 1 had become agitated and pulled on the metal pole causing it to fall and hit her in the head. RN 1 stated Resident 1 had a facial expression of distress. RN 1 stated Resident 1 had a known history of pulling on the metal pole. During an interview on 8/6/2026 at 1:24 p.m., with CNA 2, CNA 2 she witnessed Resident 1 pulling on her G-tube tubing and reaching for the metal pole her enteral feeding pump was attached to. During an interview on 8/6/2026 at 2:38 p.m., with the Director of Staff Development (DSD), the DSD stated Resident 1 had a known history of pulling on her G-tube tubing and the metal pole her enteral feeding pump was attached to. The DSD stated the metal pole and enteral feeding pump falling onto and striking Resident 1 could result in visible and non-visible injuries. The DSD stated that even if there were no outward visible injuries, there was risk for internal bleeding inside Resident 1's head. During an interview on 8/7/2026 at 12:37 p.m., with the Director of Nursing (DON), the DON stated Resident 1's known behavior of pulling on the metal pole was a safety concern for the resident. The DON stated staff were to document this known behavior and staff interventions to address the behavior, in a care plan. The DON stated Resident 1 did not have a care plan for this behavior. The DON stated a care plan would ensure staff were aware of interventions to be implemented to maintain Resident 1's safety. During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised 12/2007, the P&P indicated resident safety was a facility-wide priority. The P&P indicated the facility used a resident-oriented approach to address safety and accident hazards for individual residents. The P&P indicated staff were to identify risk factors for residents, included information obtained through observations of the resident. The P&P indicated staff were to analyze information obtained from these observations to identify specific accident hazards or risks for the resident, and target interventions to reduce the potential for accidents. The P&P indicated implementing these interventions included communicating them to all relevant staff and documenting them. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated the resident's comprehensive, person-centered care plan was to incorporate identified problem areas and risk factors associated with identified problems. The P&P indicated care plans were to be revised as information about the resident and/or their conditions changed.

Based on interview and record review, the facility failed to ensure Interdisciplinary Team (IDT, a group of health workers from different fields that work together to make and carry out one shared care plan) meetings were conducted timely for two of two sampled residents (Resident 1 and Resident 3). This failure created the potential for Residents 1 and 3 to have delayed development of a comprehensive care plan to address their physical and psychosocial needs and wellbeing.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (a general loss of brain function), dysphagia (difficulty swallowing), presence of a gastrostomy tube (a medical device placed through the skin of the abdomen directly into the stomach to deliver food, liquids, and medications), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood or remove extra waste and fluid the right way), and aphasia (a disorder that makes it difficult to speak), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hemiplegia (inability to move one side of the body). During a review of Resident 1's History and Physical (H&P), dated 3/1/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2026, the MDS indicated Resident 1 had severe cognitive impairment (a major loss of mental function-such as memory, reasoning, and orientation-that destroys a person's ability to live independently and requires constant supervision). The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of Resident 1's record titled Interdisciplinary Care Conference 4.0, dated 5/28/2026, the record indicated the care conference was in progress. The record did not indicate that the social services department, the dietary department, or the rehabilitation department had participated in the care conference or contributed input to the resident's care plan. During an interview on 7/30/2026 at 4:10 p.m., with the Director of Nursing (DON), the DON stated the IDT mainly consisted of a representative from the licensed nursing department, the social services department, and the rehabilitation department, but other disciplines were also involved. The DON stated that when an IDT Care Conference was conducted, the staff were to document the care conference the same day, or within a day. The DON stated that timely completion and documentation of IDT Care Conferences was important to ensure any necessary changes can be made timely to the resident's care plan. The DON stated two months was not an appropriate length of time for IDT Care Conference notes to go undocumented. 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included dysphagia, type 2 diabetes mellitus, chronic kidney disease, abnormalities of gait and mobility, history of falling, dementia (a progressive state of decline in mental abilities), and heart failure. During a review of Resident 3's H&P, dated 3/7/2026, the H&P indicated Resident 3 could make his needs known, but could not make medical decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderate cognitive impairment (a clear and noticeable decline in thinking skills, memory, and reasoning that begins to disrupt a person's everyday life and independent tasks). The MDS indicated Resident 3 required partial to moderate assistance from staff for toileting hygiene, showering/bathing himself, and getting dressed. The MDS indicated Resident 3 required supervision or touch assistance from staff to transition from a sitting to standing position, and to transfer between his bed and a chair. During a review of Resident 3's physical and electronic medical record, there was no evidence that the facility conducted an IDT Care Conference upon Resident 3's admission. During a review of Resident 3's record titled Interdisciplinary Care Conference, dated 6/2/2026, the record indicated staff were meeting to discuss quarterly (every 3 months) updates related to Resident 3's care. The record indicated that Resident 3 and his family had focused on rehabilitation services and discharge planning, and indicated that Resident 3 would discharge to the community once rehabilitation sessions were completed. The record did not indicate that the rehabilitation department had participated in the care conference or contributed input to the resident's care plan. During an interview on 7/30/2026 at 3:08 p.m., with the MDS Coordinator (MDSC), the MDSC stated IDT Care Conferences were to be conducted upon admission, or within 14 days. The MDSC stated the IDT Care Conferences were to be documented on paper and kept in the resident's physical and electronic medical records. During an interview on 7/30/2026 at 4:17 p.m., the DON stated Resident 3 did not have a documented IDT Care Conference upon admission to the facility. The DON stated an admission IDT Care Conference was important in allowing staff to get to know the resident and develop an appropriate plan of care. During a review of the facility's policy and procedure (P&P) titled Care Planning - Interdisciplinary Team, revised 9/2013, the P&P indicated the facility's Care Planning/Interdisciplinary Team was responsible for development of an individualized comprehensive care plan for each resident. The P&P indicated the care plan was based on the resident's comprehensive assessment and was to be developed by an IDT, which included, but was not limited to: the Dietary Manager/Dietician, the Social Services Worker responsible for the resident, therapists, and others as appropriate or necessary to meet the needs of the resident.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) had a completed Physician Orders for Life-Sustaining Treatment (POLST) form, when the POLST form did not include a resident or responsible party signature.This failure had the potential to result in the resident's treatment preferences and wishes not being known or honored in the event of an emergency.Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 5's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 5's History and Physical (H&P), dated [DATE], the H&P indicated Resident 5 did not have the capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 5's cognition (process of thinking) was moderately impaired.During a review of Resident 5's physician's order dated [DATE], the physician order indicated do not resuscitate (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR-an emergency lifesaving procedure performed when the heart stops beating or breathing ceases] if breathing stops or the heart stops beating).During a review of Resident 5's POLST form dated [DATE], the POLST form indicated there were no signatures by the resident or responsible party. The POLST form indicated there were two initials at the bottom of the form.During an interview on [DATE] at 10:43 a.m. with Resident 5 in her room, Resident 5 stated she did not have knowledge of POLST form and had not seen such form. Resident 5 stated her family member (FM 1) oversaw her care.During a concurrent interview and record review on [DATE] at 10:50 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 5's POLST form, dated [DATE], was reviewed. LVN 1 stated there was no resident or responsible party signature on the POLST form. LVN 1 stated FM 1 consents and signs forms for Resident 5. LVN 1 stated if residents are found pulseless, facility staff looks in the chart for a POLST form to determine whether to perform CPR or not.During a concurrent interview and record review on [DATE] at 10:59 a.m. with Registered Nurse (RN) 2, Resident 5's POLST form, dated [DATE], was reviewed. RN 2 stated resident's responsible party may sign POLST form if the resident was not able to sign. RN 2 stated verbal consent was obtained via phone, and the POLST form was initialed by two licensed staff in place of the responsible party's signature.During a phone interview on [DATE] at 11:12 a.m. with FM 1, FM 1 stated Resident 5 spoke about becoming DNR but did not sign a POLST form. FM 1 stated the resident does not sign paperwork unless she (FM 1) is present. FM 1 reported she had not signed the POLST and denied having any phone discussion with facility staff regarding DNR options. FM 1 stated she did not give verbal consent for staff to sign the POLST on behalf of herself or Resident 5, adding this is a sensitive topic and she only signs documents in person.During an interview on [DATE] at 12:31 p.m. with the Social Services Assistant (SSA), the SSA stated the POLST form is a legal document and should be signed by the resident or responsible party to confirm accuracy.During a concurrent interview and record review on [DATE] at 1:08 p.m. with Director of Nursing (DON), Resident 5's POLST dated [DATE] was reviewed. The Completing POLST instructions indicated to be valid, a POLST form must be signed by the patient or decisionmaker. The DON stated POLST and DNR status are reviewed upon admission, and without a resident or responsible party signature, the POLST is incomplete and the resident is treated as full code (full life-saving measure in case of an emergency). The DON stated phone consent and having two nurses sign the POLST is not allowed, and there is no facility policy permitting this.During a review of the facility's policy and procedure (P&P) titled, Informed Consent, dated 2023, the P&P indicated, When situations arise that involve complex decisions, the facility will verify that informed consent has been obtained prior to any medical intervention or treatment is initiated

Based on observation, interview and record review, the facility failed to ensure two of four sampled residents' (Residents 95 and 109) call light was placed within reach.This deficient practice had the potential for Residents 95 and 109 not to be able to call for assistance and delay the assistance needed.Findings: During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 95's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body), dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities.)During a review of Resident 95's History and Physical (H&P) dated 12/1/2025, the H&P indicated Resident 95 did not have the capacity to understand and make medical decisions.During a review of Resident 95's Minimum Data Set (MDS, a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 95 had the ability to make self-understood and the ability to understand others. The MDS indicated Resident 95 was dependent on a helper for oral hygiene, toileting hygiene, showering/bathing, and upper and lower body dressingDuring a review of Resident 95's Care Plan Report dated 4/15/2025, the care plan indicated to ensure the resident's call light was within reach. During a review of Resident 109's admission Record, the admission record indicated Resident 109 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease causing difficulty in breathing), Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia.During a review of Resident 109's H&P dated 4/19/2026, the H&P indicated Resident 109 did not have the capacity to understand and make decisions.During a review of Resident 109's MDS dated [DATE], the MDS indicated Resident 109 rarely/never made self-understood or had the ability to understand others.During a review of Resident 109's Care Plan Report dated 4/7/2026, the care plan indicated to ensure the resident's call light was within reach.During a concurrent observation and interview on 4/21/2026 at 9:39 am, in Resident 109's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the call light is not within reach for the resident if it is on the floor. Resident 109 could fall out of bed reaching for it or be in distress and we might not hear him call.During a concurrent observation and interview on 4/21/2026 at 9:41 am, in Resident 95's room with CNA 1, CNA 1 stated the call light is not within reach for the resident if it is on the floor. We would not be able to assist her if she cannot call for help.During a review of the facility's Policy and Procedure (P&P) titled Call Lights: Accessibility and Timely Response revised 10/2025, the P&P indicated staff should facilitate call light placement within reach of resident and secure it as needed.

Based on interview and record review, the facility failed to ensure care plans were developed for two of four sampled residents (Resident 73 and 97) when there were no care plans for Resident 73's diagnoses of anxiety (persistent and excessive worry that interferes with daily activities), Alzheimer's Disease (progressive mental deterioration) major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly) and Resident 97's diagnoses of anxiety, major depressive disorder, and bipolar disorder.These deficient practices had the potential to result in delayed care and services for Resident 73's and Resident 97's health.Findings:During a review of Resident 73's admission Record, the admission record indicated Resident 73 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 73's diagnoses included anxiety, Alzheimer's Disease, and bipolar disorder.During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 73's cognition (process of thinking) was severely impaired. The MDS indicated Resident 73 required substantial/maximal assistance (helper does more than half the effort) for showering/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 97's admission Record, the admission record indicated Resident 97 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 97's diagnoses included anxiety, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder.During a review of Resident 97's H&P dated 11/12/2025, the H&P indicated Resident 97 had the capacity to understand and make decisions.During a review of Resident 97's MDS dated [DATE], the MDS indicated Resident 97's cognition was moderately impaired. The MDS indicated Resident 97 required setup or clean-up assistance from staff for eating, oral hygiene, toileting hygiene, and personal hygiene.During a concurrent interview and record review on 4/23/2026 at 12:07 p.m. with the Director of Nursing (DON), the care plans for Resident 73 and Resident 97 were reviewed. The DON stated the residents should have care plans for behavioral diagnoses. The DON stated without a care plan, the interventions for the diagnoses would be delayed and staff would not know what the goals for that resident were. The DON stated staff needed to know what non-pharmacological interventions to try.During a review of the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated the comprehensive, person-centered care plan would incorporate identified problem areas and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interviews and record review, the facility failed to ensure informed consent was completed with all required elements for two of six sampled residents (Resident 2 and Resident 30).This deficient practice has the potential to result in residents receiving treatments or interventions without understanding the risks, benefits, or alternatives.Findings:During a review of Resident 2's admission record, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included anoxic brain damage (brain damage happens when the brain does not get any oxygen at all causing the brain cells to become injured or die), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (too much fat in the blood).During a review of Resident 2's History and Physical (H&P) dated 4/18/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 2's cognition (thought process) was severely impaired and never/rarely made decisions. The MDS indicated Resident 2 was dependent (helper does all of the effort) on staff for all activities of daily living and mobility.During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including heart failure (heart is too weak or too stiff to pump blood the way it should), pneumonia (an infection, inflammation in the lungs), and epilepsy (condition where a person has repeated seizures caused by sudden bursts of abnormal electrical activity om the brain).During a review of Resident 30's H&P dated 3/31/2026, the H&P indicated Resident 30 had the capacity to understand and make decisions.During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30 was able to sometimes understand and be understood by others. The MDS indicated Resident 30's cognition was severely impaired. The MDS indicated Resident 30 was dependent on staff for activities of daily living such as dressing and toileting hygiene and mobility.During a concurrent interview and record review on 4/21/2026 at 2:12 p.m. with Licensed Vocation Nurse (LVN) 1, Resident 2's and Resident 30's medical records were reviewed. LVN 1 stated the informed consent forms for ventilator (a medical device to help support or replace breathing), tracheostomy (a surgically created hole in the windpipe to create a direct airway for breathing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) lacked the physician's name and date.During a concurrent interview and record review on 4/24/2026 at 10:05 a.m. with the Director of Nursing (DON), Resident 2's and Resident 30's consent forms were reviewed. The DON stated Resident 2's and Resident 30's informed consent forms were incomplete and missing the physician's name and date, however staff changed the consent forms by adding the physician's signature and backdated to 4/16/2026. The DON stated completed informed consent forms are necessary to inform Resident 2 and Resident 30 and their responsible parties of the risks and benefits of the recommended treatment. The DON stated an incomplete informed consent fails to provide this information and may place Resident 2 and Resident 30 at risk if treatment was given without the physician's knowledge and understanding.During a review of the facility's policy and procedure (P&P) titled, Informed Consent, undated, indicated it was the responsibility of the healthcare professional who proposes any medical intervention or treatment that required informed consent to provide information to the resident/resident representative regarding the resident's condition and circumstances that are pertinent to a decision to accept or refuse the proposed intervention treatment.

Based on observation, interview, and record review, the facility failed to provide a humidifier to the oxygenator machine for one out of one sampled resident (Resident 49).This failure had the potential to allow mucous to thicken, dry, and create a mucous plug and block oxygen to the lungs.Findings:During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 49's diagnoses included chronic respiratory failure with hypoxia (long term, gradual, progressive condition where the lungs cannot adequately transfer oxygen to the blood, resulting in persistently low blood oxygen levels), tracheostomy (a surgical procedure that creates an opening in the neck for a tube to be inserted directly into the windpipe to help with breathing), and dysphagia (difficulty swallowing).During a review of Resident 49's History & Physical (H&P), dated 3/5/2026, the H&P indicated Resident 49 did not have the capacity to understand and make decisions.During a review of Resident 49's physician orders, dated 3/3/2026, the physician orders indicated to change the humidifier every night shift every Monday, Wednesday, Friday, and place on humidified O2 (oxygen) at 2 liters per minute via T-piece (a T shaped medical device connected to tracheostomy tubes to deliver oxygen to spontaneously breathing patients) every day and night shift.During a review of Resident 49's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 49's cognition (process of thinking) was severely impaired. The MDS indicated Resident 49 was dependent (helper does all of the effort) on staff for all activities of daily living and mobility.During a concurrent observation and interview on 4/21/2026 at 11:17 a.m., in Resident 49's room with the Respiratory Therapist (RT 1), Resident 49's oxygenator did not have a humidifier attached. RT 1 stated the resident has been at the facility since 10/2025 and there was no order for a humidifier. RT 1 stated that if the air from the oxygenator was not humidified, the secretions could dry up and if the resident was unable to cough up the secretions, a mucous plug could develop.During an interview with the Director of Nursing (DON) on 4/24/2026 at 11:35 a.m., the DON stated a humidifier should be used when residents are on an oxygenator and if a humidifier was not used, the secretions would thicken and can become stuck. The DON stated the dryness can cause discomfort.During a review of the facility's policy and procedure (P&P) titled Oxygen Concentrator, dated 2022, the P&P indicated oxygen was administered under orders of the attending physician, except in the case of an emergency and to attach disposable humidifier to the concentrator, if indicated.

Based on interview and record review, the facility failed to ensure sufficient numbers of nursing aides were available on weekends to provide nursing care to 10 out of 10 sampled residents in accordance with resident care plans and assessed needs.This deficient practice has the potential to result in delayed or missed care, including delays in assistance with activities of daily living (ADL, activities such as bathing, dressing and toileting a person performs daily), timely response to call lights, increased risk for falls, skin breakdown, and decreased psychosocial well-being. Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included hemiplegia and hemiparesis following cerebral infarction (loss of strength and paralysis on one side of a body following a stroke [death of brain tissue caused by a sudden lack of oxygen and nutrients]), a stage 4 pressure ulcer at the sacral region (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), and is dependent on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 8's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 8 was dependent (helper does all of the effort) on staff for toileting hygiene, standing, sitting, and transferring from bed to chair. During an interview on 4/21/2026 at 11:06 a.m., with Resident 8, Resident 8 stated the facility is always short staffed on the weekend. During an interview and record review on 4/23/2026 at 2:34 p.m. with the Certified Nurse Assistant (CNA) 9, the CNA 9 stated the CNAs call out on weekends because they do not receive support from the licensed vocational nurses (LVNs). CNA 9 stated the Charge LVN and Desk LVN, who function in supervisory roles, do not respond when CNAs request assistance with patient care and instead defer all call lights to the CNAs. CNA 9 stated management is not visible on weekends, and when staffing is very low, management does not come in to assist. During an interview and record review on 4/24/2026 at 11:01 a.m. with the Director of Nursing (DON), the California Department of Public Health (CDPH) staffing waiver, 6/25/2025, was reviewed. The staffing waiver indicated the facility shall continue to provide a minimum of 2.4 direct care service hours per patient day. The DON stated the facility has been meeting the minimum staffing of 2.4 direct care service hours per patient day. The DON reviewed the Census and Direct Care Service Hours per Patient Day (DHPPD) for December, January, February, March and April 2026 and acknowledged the facility did not meet the minimum of 2.4 direct care service hours per patient day for CNAs on the following dates: Wednesday, 12/31/2025: CNA hours 2.37 Thursday, 1/1/2026: CNA hours 2.3 Sunday, 1/11/2026: CNA hours 2.01 Friday, 2/13/2026: CNA hours 2.25 Sunday, 2/22/2026: CNA hours 2.25 Sunday, 3/1/2026: CNA hours 2.09 Thursday, 3/19/2026: CNA hours 2.22 Saturday, 3/28/2026: CNA hours 2.23 Sunday, 4/5/2026: CNA hours 2.15 Friday, 4/17/2026: CNA hours 2.25 Sunday, 4/19/2026 CNA hours 2.22 The DON stated the facility had a pattern of low staffing on weekends and did not meet the minimum requirement of 2.4 direct care service hours per patient day. The DON stated the RNs and LVNs are expected to assist CNAs with patient care and was unaware of the LVNs unwillingness to help CNAs. The DON stated she and her leadership team do not go to the facility when staffing is very low to assist with patient care. The DON stated low staffing resulted in delayed resident care, delayed responses to call lights, and resident complaints about sub-par or delay care. During a review of the facility's policy and procedure (P&P) titled, Staffing, dated 10/2017, indicated, the facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The P&P indicated licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services and staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care.

Based on observation, interview, and record review, the facility failed to ensure two of four trash bins were covered.This failure has the potential to attract pests, such as rodents and flies, to the area.Findings:During an observation on 4/21/2026 at 8:57 a.m., at the outside area where trash bins are stored, two trash bins were uncovered.During an observation and interview on 4/21/2026 at 9:25 a.m., with the Dietary Supervisor (DS), two open trash bins were uncovered. The DS stated the trash bins should be covered. The DS stated if the bins were not covered, pests, such as rodents or flies, could come into the facility, and land on the residents' food.During an interview on 4/24/2026 at 11:35 a.m. with the Director Of Nursing (DON), the DON stated the trash bins should be covered. The DON stated if the bins are not covered, flies would be attracted by the smell, and it would not be safe for the staff, residents, or visitors.During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated 10/2017, the P&P indicated all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.

Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection control when:a) Certified Nurse Assistant (CNA 9) and Licensed Vocational Nurse (LVN 3) did not implement appropriate use of personal protective equipment (PPE, special clothing or gear to wear to protect the body from getting sick) during care of two out of 10 sampled residents (Resident 18 and 65).b) Rehabilitative Nurse Assistant (RNA) 1 walked in the hallways wearing a disposable gown.c) Laundry Staff (L1) did not use a gown when folding clean linen or loading dirty linen and attended to the clean and dirty linen at the same time.These failures had the potential to result in residents being exposed to infectious agents and becoming ill. Findings: a) During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included sepsis (a life-threatening blood infection), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and dysphagia (difficulty swallowing). During a review of Resident 18's History and Physical (H&P), dated 3/20/2026, the H&P indicated Resident 18 had the capacity to understand and make decisions. During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 18's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 18 was dependent (helper does all of the effort) on staff for toileting hygiene and required partial or moderate assistance (helper does less than half the effort) from staff for eating. During a review of Resident 18's lab results dated 4/1/2026, the lab results indicated the resident had Escherichia coli (E. coli- bacteria that causes infection) in the urine. During an observation on 4/21/2026 at 1:25 p.m., an Enhanced Barrier Precautions (EBP- rules and steps used to stop the spread of germs and bacteria) sign was posted outside of Resident 18's room. The sign indicated staff must wear a gown and gloves while feeding the resident. During an observation on 4/21/2026 at 1:25 p.m. in Resident 18's room, Certified Nurse Assistant (CNA 9) was observed feeding the resident without wearing a gown or gloves. During a concurrent interview and record review on 4/21/2026 at 1:59 p.m. outside of Resident 18's room, the EBP sign posted outside of the room was reviewed. CNA 9 stated the sign indicated to wear a gown and gloves when feeding the resident. CNA 9 stated he did not wear a gown and gloves while feeding the resident and this could have caused cross contamination of infections between residents. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted to the facility on [DATE] with diagnoses including sepsis and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). During a review of Resident 65's H&P, dated 7/29/2025, the H&P indicated Resident 65 did not have the capacity to understand and make decisions. During a review of Resident 65's MDS, dated [DATE], the MDS indicated Resident 65's cognition was moderately impaired. The MDS indicated Resident 65 required substantial or maximal assistance (helper does more than half the effort) from staff for personal hygiene. During a review of Resident 65's lab results dated 3/22/2026, the lab results indicated the resident had proteus mirabilis (bacteria that causes infection) in a wound. During an observation on 4/23/2026 at 8:36 a.m., outside of Resident 65's room, an EBP sign was posted outside of the resident's room. During a concurrent observation and interview on 4/23/2026 at 8:36 a.m. outside of Resident 65's room, Licensed Vocational Nurse (LVN) 3 was observed putting on a gown and gloves. LVN 3 stated she was going to take Resident 65's respiratory rate prior to administering medications. LVN 3 removed her gloves and performed hand hygiene but did not remove the gown. LVN 3 proceeded to prepare Resident 65's medications on the medication cart located outside of the resident's room while wearing the same gown. LVN 3 administered Resident 65's medications without putting on a new gown. During an interview on 4/23/2026 at 8:42 a.m. with LVN 3, LVN 3 stated she did not remove the gown after taking Resident 65's respirations and before touching the medication cart and preparing the resident's medications. LVN 3 stated gowns are to be removed inside the room and not doing so could cause cross-contamination between residents. During an interview on 4/23/2026 at 3:24 p.m. with Infection Preventionist (IP), the IP stated EBP precautions help protect residents from infections. IP stated personal protective equipment (PPE- masks, gowns, gloves) must be worn while feeding residents on EBP, and PPE must be discarded while inside residents' rooms and before starting a new task to help avoid cross-contamination. The IP stated failing to follow EBP could increase the spread of infection. During an interview on 4/24/2026 at 1:08 p.m. with the Director of Nursing (DON), the DON stated EBP precautions were in place to help protect residents from illness and to stop germs from moving from one person to another. The DON stated EBP precautions must be followed while feeding a resident and in between tasks such as taking vital signs and preparing medications. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated 6/20/24, the P&P indicated, Gowns and gloves shall be removed and hand hygiene will be performed before leaving the room and avoid touching potentially contaminated environmental surfaces with clothing after contaminated PPEs are removed and discarded. b) During a concurrent observation and interview on 4/21/2026 at 11:05 a.m., Rehabilitative Nurse Assistant (RNA) 1 was walking in the hallway wearing a disposable gown. RNA 1 stated although she had donned the gown, she had not entered or exited a resident room and believed it was acceptable to walk in the hallway while wearing a gown. RNA 1 stated the gown should have been removed and discarded in a trash can. RNA 1 stated she had not disinfected her hands before applying gloves. RNA 1 stated staff needed to don a gown before entering a room and remove the gown before exiting the room. RNA 1 stated staff must disinfect their hands before donning gloves. During an interview on 4/23/2026 at 11:00 a.m. with the Infection Preventionist (IP), the IP stated RNA1 had previously performed perineal care (keeping the private areas of the body clean) without wearing the required PPE. The IP stated she was notified about RNA1 wearing a gown in the hallway and failed to disinfect her hands prior to donning gloves. The IP stated staff must remove PPE inside the resident's room before exiting, and hand hygiene was required before donning gloves. During an interview on 4/24/2026 at 10:05 a.m. with the DON, the DON stated staff must wear PPE (gown, mask, gloves) while providing resident care. The DON stated staff must dispose of PPE inside the resident room or in the designated large trash bins in the hallway. The DON stated staff should not exit a resident room or walk in the hallway while wearing PPE. During a review of the facility's P&P titled, Enhanced Barrier Precaution, dated 6/20/2024, the P&P indicated, facility staff shall perform hand hygiene and don gown and gloves before performing high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, and changing briefs or assisting with toileting. The P&P indicated gowns and gloves shall be removed and hand hygiene will be performed before leaving the room and avoid touching potentially contaminated environmental surfaces with clothing after contaminated PPEs are removed and discarded. c) During a concurrent observation and interview on 4/24/2026 at 8:05am with Laundry Staff (L1), a bin with wet linen was propped on the wall and window seal. L1 stated the linen was washed but not clean anymore because the window was dusty. During a concurrent observation and interview on 4/24/2026 at 8:07 a.m., with the Laundry Staff (L1), L1 did not use a gown when folding clean linen or loading dirty linen and L1 left the clean linen area to load dirty linen. L1 stated they should wear an apron when folding clean linen and they should not load dirty linen and attend to clean linen at the same time because the clean linen will be contaminated. L1 stated if the residents were given contaminated linen, they would be exposed to dirty linen. During an interview on 4/24/2026 at 11:35 a.m. with the DON, the DON stated linen would not be clean if it was leaning on the wall or window. The DON stated staff could not attend to clean and dirty linen at the same time and staff were supposed to use the apron when they wash linen because staff must protect themselves from dirty linen. During a review of the facility's P&P titled, Departmental (Environmental Services) – Laundry and Linen, dated 1/2014, the P&P indicated all soiled linen must be placed directly into covered laundry hamper which can contain the moisture. The P&P indicated employees sorting or washing linen must wear a gown and gloves and a mask may be worn if aerosolization is expected. The P&P indicated to use heavy-duty rubber gloves for sorting laundry and always wash hands after completing the task and removing gloves.

Based on observation, interview, and record review, the facility failed to ensure residents in rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23, 34, 35, 36, 38, and 40 had at least 80 sq ft of living space.This deficient practice had the potential to prevent residents from moving around the room freely or store personal items. Staff may also have difficulty providing care due to limited space.Findings:During a review of the Client Accommodation Analysis, dated 3/18/2026, the analysis indicated the facility's rooms had the following room measurements:room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 square (sq) feet (ft) per resident)room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident)room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) 3 room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 3 beds (78.3 sq ft per resident) room [ROOM NUMBER] is 235 sq ft with 2 beds (117.5 sq ft per resident) room [ROOM NUMBER] is 244.2 sq ft with 3 beds (81.4 sq ft per resident) During an interview on 4/24/2026 at 11:15 am with the Administrator (ADM), the ADM stated the rooms that do not have at least 80 sq ft of living space could have the potential to not feel like a home-like environment for those residents.During a review of the Room Variance Waiver request letter dated April 29, 2026, the letter indicated rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23, 34, 35, 36, 38, and 40 measured 235 sq ft, The letter indicated the required room size is 240 sq ft.During observations and interviews conducted from 4/21/2026 to 4/24/2026, there were no concerns observed as a result of the facility not providing residents with at least 80 sq. ft. of living space. Quality of care was not affected, and no complaints or concerns were reported by facility staff or residents.

Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Unusual Occurrence (an unexpected event or accident that results in significant harm or requires significant additional measures), which indicated the facility will report unusual occurrences that threaten the welfare, safety, or health of the resident, to the California Department of Public Health (CDPH), within twenty four (24) hours, when one of five sampled residents (Resident 1), had a right shoulder fracture (broken bone).This failure delayed the investigation by the CDPH and placed Resident 1 and other residents in the facility at risk for neglect and abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness), following cerebral infarction (ischemic stroke, a type of stroke caused by a blocked blood vessel [thrombosis or embolism], leading to tissue death [necrosis] in the brain due to lack of oxygen) affecting right dominant side (right-side of the body), other symptoms and signs involving the musculoskeletal system (pain, weakness, stiffness, swelling, and reduced mobility in bones, muscles, or joints) and other symptoms and signs involving the nervous system (motor dysfunction (weakness, tremors, gait changes). During a review of Resident 1's History and Physical (H&P) dated 1/27/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/29/2026, the MDS indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 was dependent on staff with the activities of daily living (ADLs) such as dressing, toilet use, transfer and mobility. Resident 1 was dependent with oral hygiene, toileting hygiene, shower/ bathing self, upper and lower body dressing and putting on footwear During a review of Resident 1's Change of Condition (COC) dated 3/15/2026 at 2:09 a.m., the COC indicated Resident 1 was transferred to acute hospital due to hypotension (low blood pressure) and elevated pulse rate. During a review of Resident 1's Order Summary Report dated 3/15/2026, the Order Summary Report indicated to transfer Resident 1 to a general acute care hospital (GACH) due to desaturation (a drop in the oxygen level in the blood which is considered dangerous and warrants urgent oxygen supplementation and/or treatment for lung condition. Normal oxygen saturation is between 96% and 98%), hypotension, shortness of breath, fever and for further evaluation. The order indicated bedhold (reserving resident's bed for 7 days while temporarily away from the facility, such as during hospitalization or therapeutic visits) for 7 days. During a review of Resident 1's GACH chest radiology (x-ray, process of taking pictures to diagnose and treat diseases) dated 3/15/2026 timed 5:14 a.m., the result indicated subacute (recent) appearing displaced fracture (a bone break where the fragments have moved out of alignment) of the surgical neck (narrowed, often fragile, part of the upper arm bone) of the right humerus (upper arm). During an interview on 3/26/2026 at 4:10 p.m. with Resident 1's family member (FM), the FM stated Resident 1's x-ray result at the GACH showed that Resident 1 had right shoulder fracture. FM stated on 3/17/2026 (2 days later), she went to the facility to ask about how the resident's right shoulder fracture happened. FM stated she spoke to the Director of Rehabilitation (DOR) and the Director of Nursing (DON) who were surprised about the fracture. FM stated the DOR and the DON stated the facility did not know about it (fracture). During an interview on 3/27/2026 at 2:00 p.m., the DON stated that on 3/17/2026, Resident 1's FM informed the facility of Resident 1's right shoulder fracture and were surprised to learn about it because there were no staff reports of falls or injuries involving Resident 1. The DON stated on 3/25/2026, she asked the admissions office to call the GACH to obtain Resident 1's X ray results. The DON stated the facility did not report Resident 1's fracture to CDPH because the facility did not know what happened. The DON stated it was important to report Resident 1's fracture to CDPH because it was part of ensuring the resident's safety during the investigation process. During an interview on 3/27/2026 at 2:45 p.m. with the Administrator (ADM), the ADM stated when something unusual (unexpected) occurs with a resident, the facility staff would discuss the findings among themselves to determine what happened. The ADM stated the facility was required to report such incident (unusual occurrence) to CDPH, and CDPH then determines through its investigation whether the event constitutes an unusual occurrence. During an interview on 4/6/2026 at 10:15 a.m. with the GACH Social Worker (SW), the GACH SW stated she called the facility on 3/16/2026 and informed the facility representative (name unknown) about Resident 1's right shoulder fracture. During a review of the facility's P&P titled, Unusual Occurrence, dated 3/2010, the P&P indicated, the facility should report unusual occurrences that threaten the welfare, safety, or health of patients, personnel, or visitors should be reported by the facility within twenty four (24) hours, either by telephone (with written confirmation) or by telegraph, to the CDPH.

Based on interview and record review, for one of five sampled residents (Resident 1), the facility failed to:1). Assess and investigate Resident 1's right arm pain when a Certified Nurse Assistant (CNA) reported to a Charge Nurse.2). Investigate the note posted by a family member (FM) in Resident 1's room reminding the staff to be mindful when caring and repositioning Resident 1's right arm because of the pain. 3). Investigate when the family member notified the facility on 3/17/2026 regarding the resident's right shoulder fracture (broken bone) on 3/15/2026.4). Implement its policy and procedure (P&P) titled, Accidents and Incidents - Investigation and Reporting which indicated the nurses and / or the department director or supervisor shall promptly initiate and document investigation of the incident. The Nurse Supervisor, charge nurses and / or the department director or supervisor shall complete a report of incident form and submit the original to the Director of Nursing Services within 24 hours of the incident. These failures resulted in the facility not assessing the resident's right arm pain timely, not notifying the physician and not providing the resident intervention to manage and treat the right arm pain. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness), following cerebral infarction (ischemic stroke, a type of stroke caused by a blocked blood vessel [thrombosis or embolism], leading to tissue death [necrosis] in the brain due to lack of oxygen) affecting right dominant side (right-side of the body), other symptoms and signs involving the musculoskeletal system (pain, weakness, stiffness, swelling, and reduced mobility in bones, muscles, or joints) and other symptoms and signs involving the nervous system (motor dysfunction (weakness, tremors, gait changes). During a review of Resident 1's History and Physical (H&P) dated 1/27/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/29/2026, the MDS indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 was dependent on staff with the activities of daily living (ADLs) such as dressing, toilet use, transfer and mobility. Resident 1 was dependent with oral hygiene, toileting hygiene, shower/ bathing self, upper and lower body dressing and putting on footwear During a review of Resident 1's Change of Condition (COC) dated 3/15/2026 at 2:09 a.m., the COC indicated Resident 1 was transferred to acute hospital due to hypotension (low blood pressure) and elevated pulse rate. During a review of Resident 1's GACH chest radiology dated 3/15/2026 timed 5:14 a.m., the result indicated subacute (recent) appearing displaced fracture (a bone break where the fragments have moved out of alignment) of the surgical neck (narrowed, often fragile, part of the upper arm bone) of the right humerus (upper arm). During an interview on 3/26/2026 at 1:36 p.m., the CNA 3 stated that every time she provides ADL care to Resident 1, and putting on his shirt, Resident 1 would move his right arm, and complained of pain, by moaning and saying ouch. CNA 3 stated Resident 1's right side was weak and had always complained of pain with movement. CNA 3 stated Charge Nurses had been made aware of the resident's pain (unable to recall dates and names of the Charge Nurses). CNA 3 stated that any changes in resident's condition (COC) should be reported to the Charge Nurse and documented on a Stop and Watch form (a written statement of the situation). CNA 3 stated Resident 1's pain could be a life threatening situation. During an interview on 3/26/2026 at 4:10 p.m. with Resident 1's FM, the FM stated, I noticed my dad was having pain in his right arm when his arm was touched or moved. The FM stated she posted a note above Resident 1's bed reminding the staff to be mindful when caring and repositioning Resident 1's right arm because of the pain. The FM stated on 3/15/2026 when Resident 1 was at the hospital, the chest radiology (x-ray, process of taking pictures to diagnose and treat diseases) revealed Resident 1 had right shoulder fracture. The FM stated she went to the facility on 3/17/2026 (2 days later), to ask about how the resident's right shoulder fracture happened. FM stated she spoke to the Director of Rehabilitation (DOR) and the Director of Nursing (DON) who were surprised about the fracture. FM stated the DOR and the DON stated the facility did not know about it (fracture). During an interview on 3/27/2026 at 9:48 a.m., CNA 4 stated Resident 1's complain of right arm pain could indicate a possible fracture that staff were unaware and needed to be assessed, addressed and investigated. During an interview on 3/27/2026 at 10:00 a.m. with LVN 2, LVN 2 stated, she saw a note in Resident 1's room posted by a family member indicating instruction for staff to avoid touching his right arm due to pain. LVN 2 stated she touched Resident 1's right arm to assess for swelling or redness. LVN 2 stated she did not move or extend the arm to further assess for pain on movement or changes with the range of motion. LVN 2 stated she did not call the family member to ask about the note because she assumed the family just posted. LVN 2 stated she did complete a COC and did not inform the doctor about the posted note due to the resident's pain. LVN 2 stated that if Resident 1 had pain, staff should have assessed the resident, assessed the pain level, provide medication, complete a COC and report to the doctor. LVN 2 stated that leaving Resident 1 in pain could cause discomfort and possible anxiety. During an interview on 3/27/2026 at 2:00 p.m., the Director of Nursing (DON) stated that the sign posted on the wall in Resident 1's room referred to the resident's contracted right arm. The DON stated that nurses are required to address concerns about Resident 1's right arm pain. The DON also stated that Charge Nurses were responsible for completing a COC, and that Registered Nurses (RNs) will assess Resident 1's arm and notify the physician as needed. The DON added that the risks of leaving a resident in pain include increased heart rate, elevated respirations, and anxiety. The DON stated on 3/15/2026 Resident 1 was transferred to acute hospital due to hypotension (low blood pressure) and elevated pulse rate. The DON stated that on 3/17/2026, Resident 1's FM informed us (facility) of Resident 1's right shoulder fracture and were surprised to learn about it because there were no staff reports of falls or injuries involving Resident 1. The DON stated that when she became aware of Resident 1's right arm fracture, she conducted a verbal investigation with the nurses. The DON could not provide evidence of her investigation. The DON stated she usually completes a written investigation, but in this case, she only conducted a verbal one. The DON stated she asked the admissions office on 3/25/2026 to call the hospital to obtain the X ray results. During a review of the facility P&P titled Accidents and Incidents - Investigation and Reporting dated 7/2017, the P&P indicated the Nurse Supervisor, charge nurses and / or the department director or supervisor shall promptly initiate and documented investigation of incident. The Nurse Supervisor, charge nurses and / or the department director or supervisor shall complete a report of incident form and submit the original to the Director of Nursing Services within 24 hours of the incident.

Based on interview and record review the facility failed to notify the physician regarding one of five sampled resident's (Resident 1) skin integrity. Resident 1 had an increase in moisture associated skin damage ([MASD] skin damage due to prolonged exposure to different sources of moisture such as feces, urine, sweat, or saliva), underneath both breasts and groin areas. As a result, there was a two-month delay in treatment to Resident 1's MASD. Resident 1 endured constant skin irritation under her right and left beast and groin area and was transferred to a general acute care hospital (GACH) on 7/25/2023. Resident 1 was found to have skin breakdown to both breast with malodorous (unpleasant or offensive odor), grey, and thick discharge extending to the perineal area (located between the anus and vagina). Resident 1 also had skin breakdown to the lower abdominal wall in the groin area that was malodorous and wet. Resident 1 remained in the GACH until 8/4/2023. Findings: During a review of Resident 1's face sheet (admission record) dated 8/9/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including diabetes (abnormal blood sugar), cardiomegaly (enlargement of the heart), and dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities). During a review of Resident 1's History and Physical (H/P) dated 11/14/2022, indicated Resident did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] an assessment and care planning tool), dated 3/23/2023, the MDS indicated Resident 1 could sometimes understand and be understood by others. The MDS indicated Resident 1 was totally dependent on staff for bed mobility, transfer, locomotion (moving from one area of the unit to another), dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 1 had MASD. During a review of Resident 1's Baseline Admission/Readmission Screen (BARS), dated 3/10/2023, the BARS indicated Resident 1 had right and left breast fold MASD with moist fragile skin, and abdominal fold MASD with moist tender fragile skin. During a review of Resident 1's Braden Scale ([BS] a standardized, evidence-based assessment tool commonly used in health care to assess and document a resident's risk for developing pressure injuries), dated 3/10/2023, the BS indicated a score of 13, indicating Resident 1 had a moderate risk for developing a pressure ulcer (injury to the skin and underlying tissue) related to moist skin, very limited mobility, and the resident requiring moderate to maximum assistance moving. During a review of Resident 1's care plan (CP) titled, The resident has potential/actual impairment to skin integrity of the Right Breast Fold Related to MASD, dated 3/11/2023, the CP goal indicated Resident 1 would maintain or develop clean and intact skin through the review date. The CP nursing interventions indicated to: 1. Identify and document potential causative factors and eliminate/resolve where possible. 2. Keep Resident 1's skin clean and dry. 3. Educate Resident 1 to avoid scratching her skin and to keep her hands or any body parts from excessive moisture. During a review of Resident 1's Skin Check Sheet (SCS), dated 5/16/2023, the SCS indicated Resident 1 had a very bad rash with skin discoloration, redness, and rash under her breast and private (groin) area. The SCS was signed and dated by the Certified Nursing Assistants (CNAs) and the charge nurse. During a review of Resident 1's Order Summary Report, dated 5/31/2023, the Order Summary Report did not indicate a physician order for treatment of Resident 1's MSAD to the left and right breast and groin area. During a review of Resident 1's Treatment Administration Record (TAR), dated May 2023, the TAR did not indicate treatment for Resident 1's MASD to the right and left breast and groin area. During a review of Resident 1's SCS for the month of June 2023, the SCS indicated Resident 1 had a rash underneath her breast on the following dates: 6/4, 6/6, 6/8, 6/12/ 6/17, 6/28, 6/21, and 6/22/2023. During a review of Resident 1's SCS for the month of July 2023, the SCS indicated Resident 1 had a rash underneath her breast on the following dates: 7/2, 7/5-6, 7/9, 7/13, 7/17-18, and 7/20- 22/2023. During a review of Resident 1's Interact Transfer Form V5 (ITV5), dated 7/25/2023, the form indicated Resident 1 was transferred to a general acute care hospital (GACH) for epigastric (upper abdomen) pain. The ITV5 form section for skin/wound care area was left blank and did not indicate Resident 1 had rashes, wounds, bruises, or any skin condition. During a review of the GACH's report titled, Consult to Social Work, dated 7/25/2023, the report indicated Resident 1 reported severe infections under her breast and groin area which the facility staff did not treat. The report indicated Resident 1 requested a proper wound care assessment and insisted the facility be evaluated for lack of care. During a review of the GACH report titled, Emergency Department, Physical Exam, dated 7/25/2023, the report indicated Resident 1 had hygiene issues with skin breakdown. The report indicated Resident 1 had skin breakdown to both breasts with malodorous, grey, and thick discharge going down to the perineal area, and skin breakdown at the lower abdominal wall in the groin area that was malodorous and wet. During a concurrent interview and record review on 8/18/2023 at 12 p.m., with the Wound Treatment Nurse (Licensed Vocational Nurse 1 [LVN 1]), Resident 1's TARs for the months of May, June and July 2023 were reviewed. LVN 1 stated he (LVN 1) did not review Resident 1's skin check sheet. LVN 1 stated not assessing Resident 1's skin and reviewing the skin log, may cause important skin changes go untreated and cause skin irritation to the resident. LVN 1 stated the facility needed a better system in place to communicate the residents' skin changes. LVN 1 stated he did not perform any treatments to Resident 1's breast and groin area in May, June, and July of 2023. LVN 1 stated he saw the CNAs documentations on the SCS but did not notify Resident 1's physician. During a review of the facility's Treatment Nurse's job description, dated 2003, the job description indicated the primary purpose of the Treatment Nurse was to provide primary skin care to residents under the medical direction and supervision of the resident's attending Physicians, the Director of Nursing Services, or the Medical Director of the facility, with an emphasis on treatment and therapy of skin disorders. The job description indicated the Treatment Nurse's duties and responsibilities included conferring with the Director of Nursing Services and/or other Licensed Nursing Personnel regarding dermatologic disorders of residents in the facility and examine the resident and his/her records and charts and discriminate between normal and abnormal findings, to recognize when to refer the resident to a Physician for evaluation, supervision, or directions. During a concurrent record review and interview on 8/18/2023 at 1:30 p.m., with the Director of Nursing (DON), Resident 1's skin check log for May 16 through July 24, 2023, physician order summaries for March through July 31, 2023, the TAR for March through July 2023 and the skin care plan were reviewed. The DON stated Resident 1's skin integrity care plan was not updated to reflect Resident 1's skin impairment underneath the left and right breast and groin area. The DON stated there was no documentation to indicate there was observation, monitoring or assessments performed on Resident 1's right and left breast and groin area. The DON stated there was no documentation to indicate the physician was notified from 3/10/2023 through 5/16/2023, regarding the rash underneath Resident 1's left and right breast and groin area. The DON stated, the rash underneath Resident 1's right and left breast and groin were not treated from May through July of 2023. The DON also stated Charge Nurses, Supervisors and Treatment Nurses were responsible for assessing skin changes, and communicating with the physicians, implementing physician orders, documenting the COC, and updating care plans. During a telephone interview on 8/21/2023, with Resident 1's family member (FM) 1. FM 1 stated Resident 1 had MASD underneath her abdomen and buttocks, when she was admitted to the facility and to the GACH. FM 1 stated Resident 1 complained of staff rough handling her during diaper changes and felt staff was removing her skin each time staff cleaned her buttocks. FM 1 stated the facility neglected Resident 1. During a review of the facility's policy and procedure (P/P) titled, Change in a Resident's Condition or Status, dated 5/2017, the P/P indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status including changes in the level of care. The P/P indicated the nurse will notify the resident's Attending Physician or physician on call when there was an incident involving the resident; significant change in the resident's physical/emotional/mental condition; a need to alter the resident's medical treatment, and or specific instruction to notify the Physician of changes in the resident's condition. The P/P indicated a significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. B. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident's assessment. During a review of the facility's P/P titled, Bath Shower /Tub, dated February 2018, the P/P indicated its purpose was to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. The P/P indicated the staff will dry residents from the head to the waist before assisting him or her from the tub or shower, observe skin residents for any rashes, reddened areas or skin discoloration and document all assessment data (any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. The P/P indicated to notify the physician of any skin areas that may need to be treated. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, the facility failed to provide nutrition to prevent weight loss for one of two sampled resident (Resident 87) by failing to: 1. Ensure Resident 87 received bolus feeding (a type of feeding where a syringe is used to send formula through your feeding tube) as ordered by physician and as recommended by the Registered Dietitian (RD, food, and nutrition expert) to meet the recommended daily nutritional intake and prevent severe weight loss (a loss of greater than [>] 7.5 percent [%] in 3 months). 2. Revise the care plan to reflect current diet orders or to develop a care plan to modify nutritional interventions. 3. Monitor the Resident 87's calorie (a unit of energy) intake as ordered by the physician dated 11/1/2022. 4. Provide a one-on-one (1:1, one resident assisted and supervised by one staff) feeding assistance at all times for poor po (mouth) intake as ordered by the physician on 12/26/2022. These deficient practices resulted in Resident 87 loss of 16 pounds (lbs, a unit of measure) or 8.9% of the usual weight within 3 months (from 10/1/2022 to 1/11/2023) and placed the resident at risk for further decline in nutritional status and delayed in pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous [under the skin] tissue layer) healing. Findings: During an observation in Resident 87's room on 1/9/2023 at 1:16 PM, Resident 87 was lying in bed and a meal tray was on the bedside table and out of the resident's reach. Certified Nursing Assistant (CNA) 2 was standing on the other side of the room and was having a conversation with the resident's roommate. During a concurrent observation and interview with CNA 2 on 1/9/2023 at 1:16 PM, CNA 2 stated that Resident 87 did not want to eat today when offered food. CNA 2 attempted to offer food and asked Resident 87 while standing over the resident, Do you want to eat? but the resident turned his head away from the food. CNA 2 did not encourage Resident 87 to eat by stating See, he does not want to eat, and I cannot make him. CNA 2 took the tray away from the resident's bedside and stated, I will notify the charge nurse that he refused food. CNA 2 stated when the resident did not eat, she notified the charge nurse to give the resident a bolus feeding through the gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach). CNA 2 stated that she was not aware of the resident's dietary needs or the Registered Dietitian's (RD's) recommendation other than to notify charge nurse when resident did not eat. During the same observation, on 1/9/2023 at 1:16 PM, CNA 2 left Resident 87's room with the meal tray and placed the tray in the meal cart in the hallway, to be taken away. CNA 2 entered another room to assist in feeding another resident. During a concurrent observation and interview with the charge nurse, Licensed Vocational Nurse (LVN) 5 in Resident 87's room on 1/11/2023 at 7:51 AM, Resident 87's breakfast tray was on bedside table and out of the resident's reach. The surveyor asked LVN 5 why the resident's breakfast was still on the (bedside) table. LVN 5 stated she would call the CNA. CNA 1 and CNA 2 entered the resident's room and both CNAs stated, We will pull him up then feed him. During a concurrent observation and interview on 1/11/2023 at 8 AM, CNA 1 and CNA 2 lifted Resident 87 to sit up in bed, then CNA 1 tried to feed the resident while standing over the resident. Resident 87 refused the food. CNA 1 stated Resident 87 was not eating and left the room. CNA 2 noted that the surveyor was still standing in the room and started to feed Resident 87 while standing over the resident. During an interview with CNA 1 on 1/11/2023 at 10:32 AM, CNA 1 stated that the resident most of the time ate by himself. CNA 1 said that she would report to the charge nurse and speech therapist (a health professional who assesses, diagnoses, and treats speech disorders and communication problems) that the resident was not eating. CNA 1 stated if the resident did not eat, he would lose weight. CNA 1 stated she did not know about the current recommendations from the dietitian (RD). During an interview and record review Medication Administration Record (MAR) and nursing notes with Registered Nurse (RN) Supervisor (RN 3) on 1/11/2023 at 10:41 AM, RN 3 stated the nurse who was responsible for the resident would review the recommendation of the Registered Dietitian, the doctor's order, and the resident meal status, and the nurse would notify the doctor, the kitchen staff, and then the CNA of any changes. RN 3 stated that Resident 87 should receive a bolus feeding when his meal intake was less than [<] than 50%. There was no documentation when a bolus was given (on or after breakfast). During a concurrent interview and record review of the MAR and nursing notes with LVN 5 on 1/11/2023 at 12:03 PM, LVN 5 stated she was responsible for Resident 87. LVN 5 stated she have not given a bolus feeding to Resident 87 (on or after breakfast). She said the CNA would notify her if the resident was not eating well. LVN 5 stated the resident's CNA had not notified her. LVN 5 stated she does not look at the CNA's meal intake documentation records. LVN 5 stated there were no bolus feedings given to the resident for January 2023. LVN 5 stated the resident's CNA did not notify her when the resident refused lunch on 1/9/2022. There was no documentation that the doctor was notified of the resident not eating. During an interview with Registered Dietitian (RD) on 1/12/2023 at 11:26 AM, RD stated she worked in the facility two days a week. She stated that her duties included assessment of new admissions and re-admissions, monitor weight changes that are significant, follow up progress notes, and assess monthly the residents on tube feeding (feeding through G-tube). RD stated the residents with weight loss are highest priority. She stated that she gives the recommendations to the charge nurse. RD stated that she expected the recommendations would be carried out, and the charge nurse would inform the doctor. RD stated that for Resident 87, she recommended PRN (as needed) bolus feeding when PO intake was less than 50% and for the resident to have a one-on-one feeding assistance. RD stated that she did not know where to look to see if the resident received bolus feedings. During an interview on 1/12/2023 at 11:46 AM, RD stated she discontinued the PRN bolus feeding for meals that are less than 50% and changed to a bolus feeding to make sure the resident received calories. A review of Resident 87's Admission Record indicated the facility admitted the resident on 3/22/2022 and readmitted the resident on 10/10/2022 with a diagnoses including type 2 diabetes mellitus (DM, a condition that affect the way the body processes blood sugar), pressure ulcer of the sacral region (bottom of the spine), chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) , developmental disorder of speech and language (a communication disorder that interferes with learning, understanding, and using language), and iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells.) A Review of Resident 87's Weight and Vital Summary (signs of life including heart beats and temperature) and weight record log dated 3/23/2022 to 1/11/2023 indicated Resident 87's weights were as follows: 1. 3/23/2022 =195 lbs 2. 4/09/2022 =195 lbs 3. 4/20/2022 =192 lbs 4. 5/12/2022 =190 lbs 5. 6/10/2022=193 lbs 6. 7/13/2022=197 lbs 7. 8/6/2022=190 lbs 8. 8/27/2022 = 182 lbs 9. 9/13/2022=182 lbs 10. 10/01/2022 =179 lbs 11. 10/10/2022 = 176 lbs 12. 11/1/2022 = 173lbs 13.12/13/2022 =168 lbs 14.1/11/2023 = 163 lbs A review of Residents 87's Registered Dietitians Note, dated 9/13/2022, indicated the resident with orders for weekly weights for four (4) weeks and recommended continuing (the weekly weights). A review of Registered Dietitian Note, dated 10/6/2022, indicated RD consulted due to resident having loose stools. The resident currently on regular, pureed diet (food that are blended into smooth texture without any lumps) with nectar liquids (liquids are easily pourable and are comparable to heavy syrup found in canned fruit) with variable intake from refusal to 100% intake. Resident 87 was tolerating Jevity 1.5 (nutritional supplement) at 70 milliliters (ml, a unit of measure) per (/) hour (hr) plus 35 ml/hr water flush for 2 hours via G-tube. RD noted that a speech therapist reported that Resident 87 often did not eat meals but ate several yogurts per day. A review of Resident 87's Physician Orders, dated 10/10/2022, indicated Pro-Stat Sugar Free (a medical food providing complete protein [functions as building blocks for bones, muscles, skin, and blood] for wound healing and malnutrition) in the morning for supplement 30 ml via G-tube. A review of Resident 87's care plan for nutrition, dated 10/13/2022 indicated the resident had impaired nutrition and hydration (balance between water inputs and water outputs) status related to chewing problems, dysphagia (difficulty swallowing), and G-tube feeding. Resident 87 had a significant weight loss for 3 months. The goal was for the resident to have adequate calories and protein via enteral nutrition (also known as tube feeding) to promote weight gain back towards usual body weight and wound healing. Resident 87 was on a regular diet and pureed texture. A review of Resident 87's Nutrition Screening and Assessment, dated 10/13/2022, indicated the resident's current body weight was 176 lbs and residents usual body weight was 179 to 197 lbs. The assessment indicated resident had gradually been losing weight over the past year with significant weight loss of 9.1% for 3 months related to failed attempts at weaning tube feedings, decreased food intake and pressure ulcers. The resident's estimated calorie needs were 1477 to 1773 kcal (kilocalorie, another word for calorie) per (25 to 30kcal per 59 kg [kilogram, a unit of measure] ideal body weight [IBW]) 80 to 96 grams (g, a unit of measure) (1 to 1.2 g/80 kg current body weight) and 1477 to 1773 ml fluids (1 ml/kcal). Recommended to increase Fibersource 1.2 (a nutritionally complete tube feeding formula with fiber) 70 ml/hr and 25 ml/hr water flush for 20 hrs equals 1780 kcal (including Pro-Stat) and 91 grams protein (includes Prostat) and 1634 ml water (H2O). Resident was receiving Jevity and not Fibersource. A Review of Resident 87's History and Physical (H&P), dated 10/14/2022, indicated the resident was nonverbal, bed bound and with Stage IV sacral (tailbone area) pressure ulcer (deep wound reaching the muscles, ligaments [tissues that connects the bones], and bones). A review of Residents 87's physician orders dated 11/1/2022, indicated to monitor the resident's calorie intake. A review of Resident 87's Registered Dietitians Note, dated 11/3/2022, indicated the physician ordered to stop the G-tube feeding. The note indicated there was an order for calorie count in the system, but there was no calorie count (a method of monitoring that estimates how much energy [calories] we consume each day) recorded by the CNAs for meal intakes. RD recommended for PRN bolus feeds (when the resident eats less than [<] 50% meals) Jevity 1.5, 240 ml three times a day (TID) plus 50 ml water flush before after each feed equals 1585 kcals (including Prostat), 78 grams protein (including Prostat), 1152ml water (includes extra flushes) between bolus feeds as needed. RD also requested calorie count results. There were no calorie count results documented in resident records. A review of Resident 87's Physician Orders, dated 11/04/2022, indicated for staff to administer via G-tube Jevity 1.5, 240 ml and 50 milliliters water (H2O) flush before and after each feed, every six (6) hours as needed, bolus feeds PRN (when the resident eats less than [< ] 50% at meal) TID (three times a day). A review of Resident 87's CNA-ADL (Certified Nurse Assistant-Activities of Daily Living [activities related to personal care]) Tracking form dated November 2022, indicated resident ate less than 50% and there was no documentation on G-tube feeding. A review of Resident 87's MAR, from November 2022 to January 2023, indicated an enteral (tube feeding) feed order every 6 hours as needed bolus feeds prn (when the resident eats reats <50% at meal) TID, Jevity 1.5, 240 ml plus 50 ml H2O flush before and after each feed. The MAR indicated that no bolus feeding was given when resident ate less than 50% of meal. A review or Resident 87's Minimum Data Set (MDS, standardized assessment and care planning tool) dated 12/14/2022, indicated the resident had no speech (absence of spoken words) and was severely impaired in cognitive skills (ability to think and process information). The MDS indicated Resident 87 was totally dependent (full staff performance every time during entire seven [7] day period) on staff for activities of daily living and required one-person physical assist with bed mobility, transfers, eating, dressing, and personal hygiene. The MDS indicated Resident 87 had a G-tube for medication and nutrition administration. The MDS indicated the resident had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and the resident was not on physician prescribed weight loss regimen. The MDS indicated that 26% to 50% of proportion of total calories the resident received through parenteral (intravenous or into the vein route) or tube feeding and the average fluid intake per day by intravenous (IV) or tube feeding was 500 cubic centimeter (cc, a unit of measure) per day or less. A review of resident 87's Registered Dietitians Note, dated 12/20/2022 indicated resident weight was 168 lbs, a 3% weight loss in 3 months and 13% weight loss in 6 months. RD indicated the resident's weight loss was significant. Resident 87 on regular diet, pureed texture, mildly thick consistency, Pro-Stat every day via G-tube. Resident 87 still had as needed PRN bolus feeds (when resident eats <50% meal) Jevity 1.5, 240ml TID plus 50 ml H2O flush before and after each feed. RD notes indicated resident PO intake varies per CNA notes. RD notes indicated the resident had a pressure ulcer sacrococcyx (tail bone) and the measurement, 2.2 (length) by 2.5 (width) 0.5 (depth, the distance from the top of the surface to the bottom of something), had not unchanged. RD notes indicated weight loss is related to poor intake at meals, and per CNA, the resident ate more when someone is feeding him. RD recommended 1:1 feeding at all meals for poor intake. A review of Resident 87's Physician Orders, dated 12/26/2022 Resident 87 should have 1:1 feeder at all meals for poor PO intake. A review of Resident 87's Interdisciplinary (IDT, team meeting amount healthcare professionals to discuss the Resident's plan of care) notes, dated 12/27/22, indicated Resident 87 current weight is 168 lbs and has a significant weight loss of 14 lbs from previous weight of 182 lbs (9/13/2022) for September weight. The report indicated the resident on regular, puree diet, nectar thick liquid, water flushing (via G-tube) 200 ml every 6 hours, G-tube flush 30 ml before and after medication administration, Jevity 1.5, 240 ml and 50 ml H2O if PO intake is less than 50%. The plan was to increase Pro-Stat in between meals (10 am and 2pm) via G-tube and 1:1 feeder at all meals for poor oral feeding. A review of Resident 87's CNA-ADL Tracking form dated December 2022, indicated Resident 87 ate less than 50% of meals on 4 occasions and refused food eight times. A review of Resident 87's MAR dated December 2022, indicated no bolus feeding was given to the resident. A review of Resident 87's CNA-ADL Tracking form dated January 2022, indicated Resident 87 ate less than 50% of meals on six occasions and refused food on seven occasions without a bolus feeding given. A review of Resident 87's MAR dated January 2022, indicated no bolus feeding was given to the resident. During a review of the facility's policy and procedure titled, Weight Monitoring and Management dated 2019 indicated, A plan of care addressing the significant weight variance (weight loss/weight gain) will be initiated by the licensed nurse/Dietary Supervisor/RD upon identification of the significant weight variance. Resident meeting the criteria for significant weight loss and weight gain will be weighed weekly and the director of nursing services and the weight variance committee will determine the need to initiate the weight risk note with the attending physician to address contributing factors to weight loss and interventions to manage them. During a review of the facility's policy and procedure titled, Weight change Protocol (dated 2018) indicated, the following criteria define significant for insidious weight changes: Unplanned weight loss trend that has occurred 2 times or more. 3lbs weight loss in 1 week, 5lbs weight loss in 1 month, 7.5% weight loss in 3 months and 10% weight loss in 6 months. The policy also indicated, Interventions are weekly weights, or more often, Monitors: The care plan must be revised as the goals and interventions change. The goals, interventions in the care plan should match the latest assessment.

Based on observation, interview and record review, the facility failed to follow its policy to maintain a pest-free environment and follow the pest control contractual recommendations to control and eradicate (destroy completely) flies from laying eggs in one of three sampled residents (Resident 1) [MEDICAL CONDITION] ((trach)an opening in the windpipe for breathing assistance). This deficient practice resulted in Resident 1 having maggots (immature form of a fly) crawling from and around the resident's [MEDICAL CONDITION] stoma (an opening of into the [MEDICAL CONDITION]) and had the potential for an ongoing infection. Findings: A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P), dated 3/23/19 indicated Resident 1 was non-verbal, non-ambulatory and was not able to follow commands and did not have the capacity to understand or make decisions. A review of the Pest Control service work order, provided by the company, dated 5/23/19 indicated observations were made by the pest control company and they indicated for the facility to change the fly glue board (fly trap). Another Pest control service work order, dated 6/20/19 indicated the facility's exterior service and common areas were inspected for general pest with no documentation of service provided. A review of Resident 1's nurses' note, dated 6/29/19 and timed at 6:40 a.m., indicated during a 5 a.m. [MEDICAL CONDITION], there were small white worms observed crawling around Resident 1's [MEDICAL CONDITION] stoma site. The note indicated 10 worms were removed from Resident 1's [MEDICAL CONDITION] stoma and the resident's stoma was cleansed with hydrogen peroxide. The note further indicated Resident 1's physician was notified and the resident'[MEDICAL CONDITION] changed. A review of Resident 1's physician's orders [REDACTED]. However, there was no documentation Resident 1 transferred to the ED. There was documentation as to why Resident 1 was not transferred to the ED. A review of Resident 1's nurses' note, dated 6/29/19 and timed at 6:46 a.m., indicated Resident 1'[MEDICAL CONDITION] site had redness. A review of Resident 1's nurses' note, dated 6/29/19 and timed at 9:49 a.m., indicated at 8 a.m.,[MEDICAL CONDITION] was provided for Resident 1 and there were five worm-like organism removed from Resident 1'[MEDICAL CONDITION]. A review of Resident 1's physician's orders [REDACTED]. A review of a nurses' note dated 6/29/19 and timed at 8 p.m., indicated Resident 1 had bilateral rhonchi with thick yellow secretions. During interviews on 9/17/19 at 1:24 p.m. and 9/25/19 at 11 a.m., Resident 1's Family member (FM 1) indicated on 6/29/19, she was informed by the Director of Nursing (DON) that Resident 1 had an unusual white secretions from the resident'[MEDICAL CONDITION]. FM 1 stated on 7/2/19, the DON stated Resident 1'[MEDICAL CONDITION] was cultured (collected to determine bacteria growth) (sic). FM 1 stated two months later, the facility stated maggots were found inside of Resident 1'[MEDICAL CONDITIONS] was cultured on 8/26/19. A review of Resident 1's sputum culture and sensitivity ((C/S) a test that identifies organisms and the antibiotic that is sensitive to treat the organism), dated and 8/26/19 and 9/20/19, indicated Resident 1 had heavy growth of pseudomonas aeruginosa (a bacterial infection). On 9/20/19 at 10:15 a.m., during an observation, Resident 1 was lying in bed [MEDICAL CONDITION] clean attached to a ventilator. During an interview on 9/20/19 at 10:35 a.m., DON 2 stated about three weeks prior Resident 1's family member (FM 1) asked if Resident 1 had an infection. DON 2 stated after reviewing Resident 1's clinical notes from 6/2019, Resident 1 had secretions and a sputum culture was done. DON 2 stated Resident 1's sputum culture was positive for pseudomonas (a common bacteria), and they did not know the mode of transmission but was in Resident 1's trach. On 12/13/19 at 3:22 p.m., during an interview, the Respiratory Therapy Supervisor (RTS), stated during the summertime (June-August) he was asked by the DON to follow-up and assess Resident 1's sputum to determine a difference in Resident 1's sputum (saliva and mucous). The RTS stated after his assessment of Resident 1's sputum, it was noted that the sputum was slightly yellow which was normal for Resident 1. A sputum culture was obtained per the DON instructions. On 12/18/19 at 1:37 p.m., during a telephone interview, the Registered Nurse Supervisor (RNS) stated on 6/29/19 at approximately 4 or 5 a.m., she was called by the Respiratory Therapist (RT) and he stated he had observed worm-like movement inside and around Resident 1'[MEDICAL CONDITION]. The RNS stated she observed small white maggots crawling inside and around Resident 1'[MEDICAL CONDITION]. The RNS stated she did not take any pictures, but she documented her findings and informed the DON of her observations. The RNS stated she was instructed by the DON not to document her observations in Resident 1's clinical records. The RNS stated she observed the small white worms crawling inside and around Resident 1'[MEDICAL CONDITION] again on the following day (6/30/19). The RNS stated she worked the night shift and was informed by other staff members who worked during the day that the facility had problems with flies, especially during the summertime. The RNS stated she was specifically instructed twice by the DON not to notify Resident 1's family member (FM 1) because FM 1 was aggressive and difficult at times and the DON stated it was best that she notified FM 1 herself. During an interview, on 12/18/19 at 3 p.m., the Maintenance Supervisor (MS) stated the facility had a monthly contract with a pest control company and the pest control company services the facility for flies and mice. During a concurrent review of the facility's pest control service log with the MS, there were logs from 2/26/19 through 11/27/19, but there were no service logs for 5/2019 and 6/2019 (that was obtained directly from the company). The service logs indicated the facility was treated for [REDACTED]. The MS failed to provide the service report for the months of 5/2019 and 6/2019. The MS was asked about any problems with flies in the facility during the summertime and/or at any time, the MS stated there were no problems with flies at all during 2019 (sic). On 12/18/19 at 4:08 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated during the summertime, around (MONTH) and (MONTH) of this year (2019) the facility had flies at the Sub-Acute Nurses' Station. LVN 1 stated there was always more than four (4) flies that lingered at the Sub-Acute nurses' station. LVN 1 stated she observed a glue fly trap at the nurses' station during the summertime. During an observation, on 12/18/19 at 4:15 p.m., Resident 1 was lying in bed, was non-verbal, on a T-bar ventilator (T-shaped tubing to provide air into the windpipe), with a clean dressing around stoma without a discharge from the stoma site. During a telephone interview, on 12/19/19 at 2:23 p.m., a RT stated on 6/29/19 at 6:40 a.m., he observed 10 small white worms moving around the outside of Resident 1'[MEDICAL CONDITION] and he notified the RNS of his observation. The RT stated there were lots of flies in the facility; it was summertime and that was the same time the worms were observed crawling around Resident [MEDICAL CONDITION]. The RT stated there were fly traps on the wall because the flies would keep coming back into the facility. The RT stated there were flies in the facility for weeks. According to an online Orkin pest control, the common house female fly lays up to 150 eggs, which resembles individual grains of rice, into damp, dark surfaces or in decomposing (process of decaying) materials for over a period of a few days. Within one day, the female house fly egg hatch into larvae (maggots (white legless insects that feed from the egg-laying site for three to five days)) https://www.orkin.com/fliees/house-fly/life-cycle-of-house-fly. A review of the facility's undated policy titled, Pest Control indicated for maintenance to conduct at least a weekly inspection for evidence of pest which may be conducted in conjunction with the staff's pest observation log kept at the nursing stations, document problems found during the inspections and the remedial actions taken.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure one of six sampled residents (Resident 1) was provided with adequate supervision during care to prevent falls and injuries. Resident 1, who had a high risk for falls and required a two-person physical assist in turning and care, was lying on a low air loss ((LAL) used as a pressure relieving device) mattress and was turned without using a two-person assist or any side rails and fell out of the bed sustaining injuries. This deficient practice resulted in Resident 1 falling from an elevated bed, striking her head ([MEDICATION NAME] head trauma (BHT)), sustaining a laceration to the head and the left eyeball popping out of its socket onto the floor. Resident 1 required a transfer to a general acute care hospital (GACH) for a four (4) day hospital stay. Resident 1 died two (2) months later after having complications with the left eye socket infection and a brain bleed that lead to a [MEDICAL CONDITION] (([MEDICAL CONDITION]/stroke) occurs when there was a blockage or a rupture of a blood vessel depriving part of the brain of oxygen, resulting in brain cell death). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of a History and Physical report (H/P), dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of a Minimum Data Set (MDS), an assessment and care-screening tool, dated [DATE], indicated Resident 1 had severe impairment in cognitive skills (thought process). A review of Resident 1's Brief Interview for Mental Status (BIMS) indicated a score of three (3) (,[DATE]= severe impaired cognition). According to the MDS, Resident 1 required a one-person physical assist in moving to and from a lying position, turning side to side and positioning self-while in bed, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 1 was always incontinent (inability to control) of bladder and bowel functions, was on anticoagulant (medication that thins blood and prevents stroke). The MDS, under Section S, indicated Resident 1 was receiving a comfort-focused treatment or comfort measures. A review a Morse Fall Risk Screen, dated [DATE], indicated Resident 1 had a score of 51 (45 or greater = high risk for falls). A review of a care plan, dated [DATE], indicated Resident 1 had a self-care deficit, evident by requiring assistance with bed mobility, personal hygiene, cognitive impairment and communication deficit. The staff's interventions included to keep the resident's personal items and things needed during care and bathing within the resident's reach, instruct the resident regarding safe techniques when performing activities of daily living (ADL), provide assistance with ADL and use a two-person assist during transfer. This care plan did not indicated the use of side rails for repositioning the resident during care. A review of a care plan, dated [DATE] indicated Resident 1 was at risk for falls and injury related to cognitive impairment, poor judgement, and safety. The staffs' interventions indicated to keep Resident 1's bed low, provide assistance with ADLs and remind the resident to follow safe technique during transfer. A review of the facility's in-service training indicated on [DATE] and [DATE], CNAs were educated on positioning residents on special mattresses when giving care. A review of Multidisciplinary Care Conference reports, dated [DATE] and [DATE], indicated Resident 1 was totally dependent in care and required a 2-person physical assist with bed mobility, transferring, bathing and toileting. A review of a Progress Note, dated [DATE], indicated Resident 1 was alert to verbal stimuli, but nonverbal, receiving Restorative Nursing Assistant (RNA) for range of motion (ROM) exercises to bilateral (both) upper and lower extremities. The note also indicated Resident 1 was dependent totally on the staff for all ADLs. A review of the GACH's Emergency Department (ED) provider note, dated [DATE] and timed at 7:29 p.m., indicated Resident 1 was admitted to the hospital for a [MEDICAL CONDITION] including injuries to the left eyebrow and left eye socket. According to the ED notes, the resident's left eye was missing and there was bleeding from the injured eye site. It also indicated Resident 1's computerized tomography ((CT) process in which pictures are taken to diagnose and treat diseases like broken bones or injuries to body structures) of the brain indicated Resident 1 had a [MEDICAL CONDITION], brain bleed, left eye injury and loss of consciousness for thirty (30) minutes. A review of the GACH's progress Note, dated [DATE], indicated Resident 1 had a left suborbital hematoma (swelling of clotted blood under the eye), with a five (5) centimeter (cm) deep laceration above the left eye brow that extended beneath the lower eye lid by 2.5 cm. These notes indicated there was fresh blood oozing from Resident 1's left eye. According to these notes, there were lacerations around Resident 1's left eye and conjunctiva (the membrane that covers the front of the eye and lines the inside of the eyelids) of the left eye, which were sutured and a pressure patch applied to the left eye socket. A review of the facility's Incident Witness Interview Report, dated [DATE], and timed at 3:30 p.m., indicated at approximately 3:15 p.m., Resident 1 fell from the bed, hit her head on the floor and sustained an injury to the left eye and head, while being cleaned by a Certified Nursing Assistant (CNA 1). The Incident Report indicated Resident 1 was bleeding from the left upper eyelid laceration (deep cut) and the left eyeball had popped out of the socket and was on the floor. A review of the GACH's Neuro-Critical Care Attending Note, (a medical field that treats life-threatening brain diseases, identifies, prevents, and treats brain injuries) dated [DATE] and timed at 11:06 a.m., indicated Resident 1 was admitted to the GACH for a subarachnoid hemorrhage (brain bleed) after a [MEDICAL CONDITION] and left eye trauma. A review of the GACH's Discharge Summary, dated [DATE], indicated the resident was treated with antibiotics (medication to prevent and treat bacterial infections), and pain medications for comfort. According to the Discharge Summary, Resident 1 was able to open her right eye. A review of the facility's follow-up report, dated [DATE], indicated Resident 1 was totally dependent on the staff for ADLs and was at risk for falls and prevention actions included the use of a low bed, frequent observation, and assist Resident 1 with transfers and a clutter free environment. On [DATE], at 8:50 a.m., during an interview, the Director of Nursing (DON) stated that Resident 1, who had a LAL mattress slid off the bed in the presence of CNA 1. The DON stated that LAL mattresses where slippery and had no place for a resident to hold on to, to prevent sliding off the bed. At 10:01 a.m., on [DATE], during an interview, Resident 1's family (FM 1) stated that before the accident, Resident 1 was not on a low bed. FM 1 stated that it was totally out of protocol for one staff to be turning the resident given that the LAL mattress was slippery and the resident was not fully cooperative. On [DATE], at 11:25 a.m., during an interview, Resident 1's roommate (Resident 2), who was awake and alert stated that on [DATE], during care, Resident 1 who had a tendency of rocking back and forth in bed, tried to grab a pad on the LAL, but was unable to. Resident 2 also stated that Resident 1 tried to grab her feeding pole but the pole went towards Resident 2. According to Resident 2, Resident 1 slid off the bed and her head hit the floor so hard that the resident's eye fell out. At 12 p.m., on [DATE], during an interview, Registered Nurse 1 (RN 1) stated that on [DATE], at approximately ,[DATE]:30 p.m., during care, Resident 1 who had no floor mats or side rails, slid off the bed, landed on the bare floor and on her face, causing the socket of her eye to fall out. RN 1 stated that CNA 1 should have had another staff when caring for Resident 1 to prevent falls and injuries. According to RN 1, side rails were used as an enabler for residents to reposition themselves in bed. On [DATE] at 10:42 a.m., during an interview and a review of a written declaration, CNA 1 stated that on [DATE] between the time of 3 p.m. and 3:30 p.m., she was providing care to Resident 1 alone with bed elevated. CNA1 stated Resident 1, who was laying on a LAL mattress without the use of bedside rails and no floor mats, slid off the bed and landed on her head. CNA 1 stated that the force of Resident 1 fall caused the resident's eyeball to come out of the socket. CNA 1 stated she should have asked another staff member to stand on the other side of the bed or raised the side rails raised to prevent the resident from falling over. CNA 1 stated that Resident 1 was turned to the right side was moving to the left side to continue care, the resident went over the right side so fast because the LAL mattress was slippery and there was no side rails for Resident 1 to hold on. According to CNA 1, she tried to grab the resident's legs but Resident 1 continued to slide off the bed, the resident attempted to grab onto a feeding pole to no avail. CNA 1 stated that Resident 1 hit her head on the feeding pole and the force of the fall caused the pole's wheels to disconnect. CNA 1 stated that there was blood all over Resident 1's bedside, the resident did not make any noise and that another staff member found the resident's eyeball on the floor. CNA 1 stated she was never instructed to use another staff when turning the resident. A review of a Change in Condition Evaluation (C[NAME]) report, dated [DATE], indicated Resident 1 had a left eye infection, labored breathing and congestion. This report indicated Resident 1 was in pain, but the resident was unable to rate the pain level. The C[NAME] indicated Resident 1's [DIAGNOSES REDACTED]. A review of Nurses Notes, dated [DATE] and timed 9:42 p.m., indicated at 7:50 p.m., while a CNA was changing Resident 1, the resident's respirations were increasing and slowing down. These notes also indicated within minutes, the staff was unable to obtain Resident 1's vital signs. A review of another note, on the same day ([DATE]), timed at 9:50 p.m., indicated upon assessment of Resident 1, Registered Nurse 1 (RN1) observed the resident to be pale, with no respirations and no pulse (no heart beat). It also indicated Resident 1's vital sign reading could not be detected. On [DATE], at 11:29 a.m., during an interview, RN 3 stated on [DATE] during the ,[DATE] shift, CNA 4 noticed that Resident 1 was breathing differently. RN 3 stated that upon assessment, Resident 1 did not have a pulse and no respiration, was pale and warm. RN 3 stated that Resident 1 did not have a change of condition prior to that moment. RN stated the physician was notified and Resident 1 was pronounced dead. At 1:05 p.m., on [DATE], during an interview, CNA 4 stated that prior to Resident 1 losing her left eye; the resident was able to give eye contact. CNA 4 stated that after Resident 1's accident, the resident's condition declined and then she died suddenly. CNA 4 stated, Maybe if the resident did not have a fall, the resident could have still be alive. A review of a Physician's Discharge Summary, dated [DATE], indicated Resident 1 was in the facility from [DATE] to [DATE], a total of sixty-seven (67) days. It also indicated Resident 1 expired and was discharged to a mortuary. On [DATE], at 11:58 a.m., during a concurrent record review and interview, Resident 1's Ophthalmologist's ((OP) eye doctor) assistant stated that the resident's last eye examination before the incident was on [DATE]. The OP stated that Resident 1 did not have any diabetic retinopathy (loss of vision due to high blood sugar) or hypertensive retinopathy (loss of vision from high blood pressure) and no bleeding. The eye pressure was normal and the resident was able to follow the direction of the light. According to the OP, Resident 1's exam was normal for her age prior to the accident. The OP stated that there were four (4) main muscles holding the eyeball in place and for Resident 1's eyeball to have popped out, the resident must have fallen from a very high level. On [DATE] at 8:10 a.m., during an interview, Licensed Vocational Nurse (LVN 1) stated that before the accident on [DATE], Resident 1 was bed ridden, not contracted and able to give eye contact to the staff. On [DATE], at 3:29 p.m., during an interview, a Customer Service Representative for the LAL mattress Company stated that LAL mattresses were slippery and the facility's staff had to take precautions to prevent falls and injury to the residents. On [DATE] at 2:19 p.m., during an interview, Restorative Nursing Assistant 1 ((RNA 1) an expanded role for the Certified Nurse Assistant) stated that Resident 1 was able to move both hands, but required assistance in moving her feet in bed. A review of a death certification, dated [DATE], indicated Resident 1's immediate cause of death was acute [MEDICAL CONDITION]. A review of the facility's policy titled, Falls Management Program, with a revised date of ,[DATE], indicated the purpose of the policy was to ensure residents were provided a hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. It also indicated the licensed nurses would observe residents and review risk factors that may contribute to a fall. A review of the facility's policy titled, Support Surface Guidelines, with a revised date of ,[DATE], indicated the staff would assess residents who could reposition independently to determine the need for assistive devices that will help to maintain independent positioning. A review a policy titled, Resident Safety, with a revised date of ,[DATE], indicated the purpose of the policy was to maintain resident's safety, prevent falls and reduce recurrence of falls and injury.

Based on interview and record review, the facility failed to follow its policy by not ensuring adequate monitoring and supervision for one of three sampled residents (Residents 1). Resident 1, who had three visitors after hours, was found unresponsive, transferred to the general acute care hospital and treated for [REDACTED]. This deficient practice resulted in Resident 1 being found unresponsive and transferred to the GACH's intensive care unit ((ICU) specialized unit of the hospital used to treat critically ill patients). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 10/17/17, indicated Resident 1's cognition (thought process) was moderately impaired and had a Brief Interview for Mental Status (BIMS) score of 11 (a score of 8 to 12 = moderately impaired). The MDS indicated Resident 1 required extensive assistance with transfers, dressing, toilet use and personal hygiene. According to the MDS, Resident 1 had impairment to both lower legs. A review of Resident 1's care plan, dated 1/9/18, indicated the resident preferred to engage in self-directed leisure activities and that the staff would provide 1:1 room visits for social interaction. A review of Resident 1's Progress Note, dated 1/19/18, and timed at 9:07 p.m., indicated the resident did not receive the scheduled dose of blood pressure medications because the blood pressure reading was low. A review of Resident 1's Progress Note, dated 1/20/18, and timed at 1:30 a.m., indicated Resident 1 complained of generalized body pain and at 10:40 p.m., on 1/19/18, Licensed Vocational Nurse 1 (LVN 1) indicated there was a male family member at Resident 1's bed side. A review of a Progress Note, written by Registered Nurse 1 (RN 1), dated 1/20/18, and timed at 4:20 a.m., indicated at 11:30 p.m., on 1/19/18, Resident 1 was observed sleeping in no respiratory distress with family at the bedside. The note indicated at 2:20 a.m., LVN 1 notified RN 1 that Resident 1's family was doing illegal drug activity at the bedside. The note indicated RN 1 entered resident's room, and Resident 1's visitors were observed outside of the facility talking with the police. The note indicated at 2:45 a.m., Resident 1 was observed to be sleeping, snoring, and in no respiratory distress. At 3 a.m., Resident 1 was breathing evenly but unresponsive to verbal or painful stimuli. The resident's vital signs (V/S) were noted to be as follows: Blood Pressure (BP) 78/50 ((Normal Reference Range (NRR)) = 120/80), heart rate (HR) 61 beats per minute (NRR= 60-100), Respiration Rate 12 (NRR = 12-20), blood sugar 191 (NRR = 70-120), O2 saturation (sat) 87% (NRR = 90-100). According to the note, LVN 1 stated Resident 1 remained unresponsive and Code Blue (medical emergency in which one requires resuscitative efforts) and 911 were called. When the paramedics arrived, Resident 1 was administered [MEDICATION NAME] (medication used for partial or complete opioid reversal) two times but remained unresponsive and was transferred to the GACH. A review of a Progress Note, dated 1/20/18, and timed at 7:24 a.m., indicated Resident 1 was observed by Licensed Vocational Nurse 1 (LVN 1) sleeping while there was a visitor at the bedside who stated they were Resident 1's family member. The note indicated, during the night, three visitors at the resident's bedside would not leave when asked and the staff notified the local police department who came and arrested two of the visitors. The note indicated at 3 a.m., Resident 1 was observed to have been sleeping more than usual, was assessed and noted to be unresponsive and a Code blue was initiated and 911 was called. The paramedics arrived to the facility within 7 minutes, administered [MEDICATION NAME] (medicine used for opioid reversal) two times but the resident remained unresponsive; and was transferred to the GACH. A review of the facility's Incident Log, dated 1/20/18, indicated Resident 1 was found unresponsive at 3:10 a.m., of the same day, and 911 was called and the facility's staff closely monitored the resident until the paramedics arrived. A review of Resident 1's physician's orders [REDACTED]. A review of the facility's Investigation Report, dated 1/22/18, indicated on 1/19/18 Resident 1 had family members at the bedside until the early morning of 1/20/18. The report indicated Resident 1's family members were engaged in illegal drug activity in the resident's room and the police were called. According to the report, the licensed nurse assessed Resident 1 and found the resident was unresponsive to voice or touch stimuli and the paramedics were called and the resident was transferred to the GACH. A review of Resident 1's GACH's Physician Order, dated 1/20/18, indicated the resident was admitted with [DIAGNOSES REDACTED]. The order indicated Resident 1 was intubated (tube inserted into the lungs to help a patient breath). A review of Resident 1's laboratory (lab) results indicated the resident's urine tested positive for opioid's and bacteria in the blood. A review of Resident 1's GACH Physician's Progress Note, dated 1/20/18, indicated the resident was admitted to the intensive care unit ((ICU) specialized unit of the hospital for critically ill patients). The note indicated Resident 1 was confused, unable to follow commands, and had non-purposeful upper body movements. On 1/24/18 at 5:51 a.m., during an interview, Registered Nurse 2 (RN 2) stated the facility doors were locked between the times of 11 p.m. to 5 a.m. daily. On 1/24/18 at 6:18 a.m., during an interview, LVN 2 stated the doors were locked at night and visitors had to ring the bell to be let in. LVN 2 stated there was no specific time indicated for visiting hours. On 1/24/18, at 6:25 a.m., during an interview, LVN 3 stated he worked the night of 1/20/18, when Resident 1 was found unresponsive. LVN 3 stated that Resident 1's family members were at the bedside. LVN 3 stated that one of the family members had something suspicious looking in a cup and the police were called and within an hour, Resident 1 was found unresponsive. On 1/24/18 at 6:51 a.m., during an interview, the facility's Administrator (ADM) stated the facility's doors locked at 9 p.m. and that visiting hours were between 11 a.m. to 8:30 p.m. The ADM stated that the facility was lenient on visiting hours and provided families with an opportunity to see loved ones at any time. According to the ADM, Resident 1's family came to the facility around 8 p.m., on 1/19/18, and the resident seemed to enjoy their company. The ADM stated that no one asked the family members to leave, until LVN 1 suspected something was wrong and called LVN 4 to verify her findings. The ADM stated that LVN 4 saw a drug pipe and what looked like drugs in Resident 1's room. The police were called and Resident 1's visitors were asked to leave. According to the ADM, the staff assessed Resident 1 and found him to be unresponsive. The ADM added that 911 was called and the resident was transferred to the GACH. The ADM stated the Director of Nursing (DON) called the GACH to inquire on the status of Resident 1, and the DON was told the resident was treated for [REDACTED]. On 1/24/18 at 7:04 a.m., during an interview, Resident 1's roommate (Resident 2) stated, on 1/20/18, Resident 1's family members were in and out of the bathroom and at 2 a.m., they were still there. Resident 2 stated he was mad and told the nurse to put the visitors out. On 1/24/18 at 8 a.m., during a phone interview, LVN 1 stated that when she took over Resident 1's care at 11 p.m., the outgoing nurse (LVN 5) informed her that Resident 1's family member 1 (FM 1) was visiting from out of state. LVN 1 stated Resident 1 was sleeping and FM 1 was doing her make-up. LVN 1 stated at 12 a.m., FM 1 stated she came from out of state and would be staying in the facility for a while. LVN 1 stated she informed FM 1 to not enter in and out of the facility because residents were sleeping. According to LVN 1, at 1 a.m., FM 1 stuffed a piece of paper in the entrance door to prevent it from locking and left the facility. LVN 1 noticed and removed the paper from the door. LVN 1 stated that FM 1 rang the doorbell shortly after and a staff let her enter. At 1:15 a.m., LVN 1 stated she went to Resident 1's room and noticed there were 2 additional male visitors with FM 1. According to LVN 1, she called LVN 3 and 4 to assist with removing the visitors from the facility. LVN 1 stated FM 1 had what appeared to be illegal drugs in a cup. LVN 1 stated the police came and the visitors were escorted out. At approximately 2 a.m., LVN 1 stated she returned to Resident 1's room and noticed the resident was still sleeping. According to LVN 1, the resident never slept for long periods of time. LVN 1 assessed Resident 1 and noted that his V/S were abnormal and RN 1 was notified. LVN 1 stated Resident 1's breathing was shallow, had no pulse, and a code blue and the paramedics were called. LVN 1 stated the paramedics gave Resident 1, two vials of [MEDICATION NAME] but the resident remained unresponsive, and was transported to the GACH. LVN 1 stated that the presence of FM 1 at the bedside coupled with the in and out movement was risky for everyone in the facility. ON 1/24/18 at 8:35 a.m., during an interview, LVN 4 stated Resident 1's room had an odd odor, and a white powder substance was observed on the floor with a cigarette next to the sink. LVN 4 stated FM 1 was fidgeting, did not make eye contact, and her face had red dots. LVN 4 stated another male visitor was appeared lethargic and speaking slowly. LVN 4 stated FM 1 was observed with a marijuana (psychoactive drug) pipe. On 1/24/18 at 11:08 p.m., during an interview, Resident 1's spouse stated Resident 1 was on life support at the GACH and was alert and oriented prior to the incident on 1/20/18. A review of the facility's policy and procedure titled, Visitation, dated 3/2010 indicated the facility's policy was to allow access to residents by families and friends to the extent that the residents rights require. The policy indicated the facility provided 24-hour visitation hours. A review of the facility's policy titled, Routine Resident Checks, with a revision date of 7/2013, indicated staff shall make routine checks to ensure resident safety and well-being.

Based on observation, interview, and record review, the facility failed implement its policy and procedures by failing to prevent one of three sampled residents (Resident 1) from being neglected by certified nursing assistant during nursing care. This deficient practice resulted in Resident 1 sustaining a [MEDICAL CONDITION] ulna (broken left forearm). Findings: A review of Resident 1 admission face sheet indicated Resident 1 was admitted to the facility, on 3/15/14, with [DIAGNOSES REDACTED]. A review of Resident 1's care plan, initiated 3/19/17, indicated Resident 1 had a potential for fracture related to [MEDICAL CONDITION]. The care plan goal included for the resident not to experience any fracture, and one of the nursing interventions was for staff to handle resident gently during turning and repositioning. A review of the Minimum Data Set (MDS - an assessment and care-screening tool), dated 5/22/17, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 11, the category of Functional Status indicated Resident 1 required extensive assistance with one person assist during transfer, toileting, and bed mobility. A review of the Nurse Notes, dated 7/20/17, at 8:30 a.m., indicated Resident 1 was in pain and adamant about not touching her left arm. The Nurse Notes, dated 7/20/17, at 1:37 p.m., indicated the x-ray was done, and the physician was notified of the x-ray results. According to Resident 1's left arm x-ray results, dated 7/20/17, there was an impression of a recent oblique fracture distal shaft of ulna (broken forearm). A review of Resident 1's Nurse Notes, dated 7/20/17, indicated at 3:20 p.m., the resident was transferred to a general acute care hospital and returned to the facility at 9:15 p.m. The Nurse Notes indicated Resident 1 had splint on her left forearm upon return. On 8/2/17, at 10:46 a.m., during an observation, Resident 1 was in her room, lying in bed awake and alert. It was observed Resident 1 had an ace bandaged splint on her left arm. The bandage expanded from Resident 1's upper to lower left arm. On 8/2/17, at 10:47 a.m., during an interview, Resident 1 stated that at about 12 at night (7/20/17) a Certified Nursing Assistant (CNA 2) came into her room and told her that she needed to change her diaper. Resident 1 stated that she (CNA 2) began folding her covers down toward her feet. The resident stated she then began to fold down her sheet. It was at this time that CNA 2 told her, I can't wait for that, I need to change you. Resident 1 stated that CNA 2 grabbed her right arm and yanked her left arm. The resident stated she told CNA 2 that her arm hurt and CNA 2 replied, I don't care. Resident 1 stated she was lying in bed in pain. Resident 1 stated that CNA 2 seemed rush as though she was in a hurry. Resident 1 stated she feels safe now that she does not see CNA 2 anymore. Resident 1 stated that she has not had a problem with any other staff member. On 8/3/17, at 6:52 a.m., during an interview, CNA 1 stated on the day following the incident he asked Resident 1 What happened?, and Resident 1 stated that a nurse was helping her the night before and Roughly yanked her arm. CNA 1 stated that Resident 1 was believed to be aware of her need and communicates clearly. CNA 1 stated the resident did not like being rushed. CNA 1 was familiar with all forms of abuse and stated he would report any form of abuse to the charge nurse or ombudsman. On 8/3/17, at 7:01 a.m., during an interview, LVN Charge Nurse 1 stated CNA 1 approached him and stated that Resident 1 verbalized complaints of left arm pain and was unable to move her left arm. LVN Charge Nurse 1 stated he called the Supervising Nurse 2 and informed her of what CNA 1 disclosed. LVN Charge Nurse 1 stated he assessed Resident 1 who verbalized pain and the resident was unable to move her arm. LVN Charge Nurse 1 asked Supervising Nurse 2, What happened? and she replied I'm not sure. LVN Charge Nurse 1 stated it was at this time that Supervising Nurse 2 called the doctor and obtained an order for [REDACTED].>A review of the facility policy, dated 6/2017, titled Abuse Prevention, indicated it was the policy of the facility that each resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. All reported incidents of resident abuse, mistreatment, neglect, and injuries of unknown would be promptly and thoroughly investigated.